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Health Surveillance in Europe

European Global Oral HealthIndicators Development Project2003 Report Proceedings

With contributions by:

Denis M. BourgeoisRuth BonitaMarie Hélène LeclercqPoul Erik PetersenHelen WheltonManuel BravoJuan Carlos Llodra Frederico SimónKenneth A. EatonPierre C. BaehniJaap P. VeerkampErik SkaretAnne Nordrehaug ÅstrømOla HaugejordenLisa Boge ChristensenJoana C. CarvalhoJean Pierre Van NieuwenhuysenCarina KällestålAnne Nordblad Annamari NihtiläGérard DuruNicolas Nicoloyannis


European Global Oral HealthIndicators Development Project

2003 Report Proceedings

EditorsDenis M. Bourgeois Juan Carlos Llodra

European CommissionHealth and Consumer Protection Directorate-GeneralCommunity Action Programme on Health Monitoring

ISBN 2-912550-31-99:HSMJLC=ZZUXV[:

BOURGEOIS_3528_couv2 14/04/04 16:56


European Global Oral Health Indicators Development Project


Edited by

Denis M. Bourgeois

Department of Public Health, Dental Faculty, University of Lyon, France

Juan Carlos Llodra

Department of Preventive Dentistry, Dental Faculty, University of Granada, Spain

Project supported by the European CommissionHealth and Consumer Protection Directorate-General

Paris, Berlin, Chicago, Londres, Tokyo, São Paulo, Barcelone, Istanbul, New Delhi, Moscou, Prague, Varsovie

This project received a financial support of the European Commission.

Neither the European Commission nor any person acting on behalf of the Commission is res-ponsible for the use which might be made of the following information.

The authors alone are responsible for the views expressed in this document.

© 2004 Quintessence International11 bis, rue d’Aguesseau75008 ParisFrance

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrievalsystem or transmitted in any form or by any means, electronic, mechanical, photocopying orotherwise, without prior written permission of the publisher.

Typesetting: STDI, Lassay-les-Châteaux, France Printing and Binding: EMD, Lassay-les-Châteaux, France

Printed in France

ISBN 2-912550-31-9


European Global Oral Health Indicators Development Project


Special acknowledgments for their contributions to the 2003 report proceedings:

Pierre BaehniManuel BravoRuth BonitaDenis M. BourgeoisJoana CarvalhoSylvie ChartronJacques DesfontaineAlejandro CeballosLisa Boge ChristensenGérard DuruKenneth A. EatonOla HaugejordenThomas HoffmannCarina KällestälPaul KarsentyDenis F. KinanePaul LangmaidMarie Hélène LeclercqMaddelon LentersJuan Carlos Llodra CalvoCesar Mexia de AlmeidaHenri MicheletCatherine Miller

Gianluigi MorcianoMichèle Muller-BollaAnnamari NihtiläAnne NordbladAnne Nordrehaug ÅstrømDenis O’MullaneLivia OttolenghiElpida PaviPoul Erik PetersenNigel B. PittsPaul RiordanGabrielle SaxEgita SenagolaFrederico SimónErik SkaretLaura StrohmengerJudit SzokeJean-Pierre Van NeuwienhuysenJaap VeerkampAlfonso Villa VigilHelen WheltonEeva WidströmGernot Wimmer

4

Contents

European Global Oral Health Indicators Development. The Challenge

7

Denis M. Bourgeois

Conceptual Positioning within International Experience

17

Indicators in health: The WHO Stepwise approach, a framework for surveillance 19

Ruth Bonita

Cross-country applicability of social survey indicators: the contribution of the Second International Collaborative Study on Oral Health Outcomes, the ICSII 26

Marie Hélène Leclercq

Basic indicators for development of quality of oral health systems in Europe – the approach of the World Health Organization 39

Poul Erik Petersen

Efficiency in Oral Health Care. The Evaluation of Oral Health Systems in Europe 48

Helen Whelton

Dental Manpower: Specific situation in Spain 60

Manuel Bravo, Juan Carlos Llodra and Frederico Simón

Oral Health Indicators: Major issues

67

Factors Influencing Demand and the Perceptions of Individuals, Dental Professionals and the Funders of and Legislators for Oral Health Care in Europe 69

Kenneth A. Eaton

Surveillance, epidemiology and periodontal diseases 81

Denis M. Bourgeois and Pierre C. Baehni

The development of the extended youth consultation 93

Jaap P. Veerkamp

Oral Health-Related Quality of Life (OHRQoL): Review of existing instruments and suggestions for use in oral health outcome research in Europe 99

Erik Skaret, Anne Nordrehaug Åstrøm and Ola Haugejorden

5

Oral Health Indicators: National views

111

National oral health information system, some Danish experiences 113

Lisa Boge Christensen

Concise review on the provision of oral health care, oral health status and oral health indicators in the Belgian population. 118

Joana C. Carvalho and Jean Pierre Van Nieuwenhuysen

European Global Oral Health Project - Critical analysis of oral health determinants 123

Carina Källestål

Information needed for regulating oral health services: a Finnish perspective 127

Anne Nordblad and Annamari Nihtilä

Oral Health Indicators: Achievements and Perspectives

131

Are the “Quality Adjusted Life Years” and “Disability Adjusted Life Years” indices trustworthy? 133

Gérard Duru

Oral Health Indicators in Europe: Preliminary consultation on the information available in 15 EU countries 139

Nicolas Nicoloyannis, Marie Hélène Leclercq and Denis M. Bourgeois

European Oral Health Indicators Workshop on Oral Health Statistics

155

Consensus Report 157

Summary Report 165

List of Participants 166

7


Denis M. Bourgeois

1

Introduction

Numerous projects have been proposed bydifferent teams from European countrieswithin the framework of the Communityaction programme in the area of health sur-veillance. The community programme ofhealth surveillance was launched in 1997by the European Community as part of itsduty with respect to public health. Themajor objective of this programme was tocontribute to establish a community sys-tem for health surveillance. It embodied

three specific objectives

2

: (i) to developcommunity health indicators through acritical review of existing data and indica-tors; (ii) to enable the realisation of a reli-able communication system for data andhealth indicators transfer and sharing; (iii)to define the necessary methods andinstruments for analysis activities and theproduction of reports on health status,

trends, and policies’ impact on health. Allthe results of the various projects spon-sored by the Programme of CommunityAction in the field of public health (1997-2002) are accessible on the Website of theEuropean Commission

3

.The project titled “European Global OralHealth Indicators Development” (EGO-HIDP) has been developed under the aus-pices of this Programme. It is one of thelatest pathfinder projects financed in 2002within the framework of the Health Sur-veillance Programme. The first phase ofthe Project terminated and the final reportwas produced in February 2004. The sec-ond phase is currently ongoing.The purpose of the European project

onGlobal Oral Health Indicators Develop-ment Project (Convention SPC 2002472)is to establish priorities for a specificallyEuropean context in coordination with theexisting programme and to make new

1. Project Leader. Faculty of Dentistry, University of Lyon, France.

2. In: Dossier Information en santé. Développements européens. Vue d’ensemble. J. Ryan &F. Sicard. ADSP, 42: 19-21.3. See http://www.europa.eu.int/comm./health/ph_projects/monitoring_projects_en.htm

8

recommendations for improving healthsystem performance when necessary.The argument in favour of developing aplan linked to oral health indicators withinthe European Programme of Surveillanceis based on an analysis of the current situ-ation and the need to organize oral healthsystem monitoring. There are a number ofadvantages to oral health indicators.

In the first place

, the rationale for a planconnected to oral health indicators isobviously related to the impact of diseaseupon society. Yet the oral health of Euro-pean populations is generally satisfactory.At least in countries within the Union, itgreatly improved in the recent past. Ananalysis of the literature on this subject istelling: between 1970 and 2000 improve-ment among children rose from 50 to80%. Similarly, most cavities were treated.These are predominantly cases of qualitydental care, meaning more fillings andfewer extractions.Even more remarkable is the fact that thestate of dental health among Europeanpopulations, including adults, appears tohave been “internationalised”. Thus theindex of serious tooth decay (DMFT) isgenerally the same for all Europe, as are itscomponents D, M, F, although countriessuch as Spain and Greece noticeably devi-ate on this point.The variability of the extent of tooth decayobserved in the 1970s has greatlydeclined. All the countries within theUnion are currently converging on a seri-ous decay threshold at age 12, varyingaround 1-1.5 DMFT. Only adults aged 65-74 present significant differences regard-ing the rate of tooth loss in Europe. These

differences are related to sanitary condi-tions and historical cultural customs, butshould rapidly disappear in future genera-tions. This analysis also covers periodontaldisease. In its severe form, periodontal dis-ease could affect 10% of all Europeanadults in a few places.It might therefore seem obsolete to recom-mend promoting national monitoring sys-tems to evaluate health results based onthe severity of the incidence of toothdecay, given that all the clinical indicatorstraditionally utilised are improving so sig-nificantly that they are heading towards azone of “good dental health,” as it mightappear frivolous in light of the “globalisa-tion” of dental health in Europe.Especially since it is obvious that we areforever past the dramatic dental health sit-uation of the 1970s, even if the literaturewere to contain warning signs of a possi-ble decline in the dental health of Euro-pean children. Actions undertaken to con-trol and prevent tooth decay have had aconsiderable effect on current genera-tions. The probability of a significant over-all decline in the medium term is slightand without a major impact on the healthsystem, even if we are unprotected fromminor recurrences in various places.

Secondly,

the monitoring system for toothdecay via the WHO data bank has existedsince 1969. Data on periodontal diseasewas added in 1985 via the CPITN index. In1995 the data bank was even relayed tothe WHOCC of Malmö University web-site

1

, which produced a national synthesisof actualised oral health data for the Inter-net. Syntheses of epidemiological informa-tion thus have been produced regularly.

1. Website: http://www.who.collab.od.mah.se


9

Health goals for the year 2000 were evalu-ated on the basis of these syntheses, aswere recommendations to the year 2015 –in short, most policy directives concerningoral health promoted by the WHO.

Nevertheless, despite the great achieve-ments of oral health in European coun-tries in the last 20 yrs, an unsolved andongoing problem still remains.

The indicator of the incidence of serioustooth decay

(DMFT) is the international refer-ence in the area of oral health. Its 40-year his-tory is an undeniable asset in evaluating pastand future trends. Yet, developing an up-to-date representative epidemiological studyutilizing the methodology of oral health mon-itoring in most cases invariably leads to simi-lar results among low-risk or even slight-riskcategories. Therefore, only limited informa-tion gains, without any real operationalimplications, are derived from a significantinvestment. The problem is not so much theusefulness of the CAOD index, but its capac-ity to translate the short-term health changesand perceptions within oral health systems.

The practice of dentistry has undergoneseveral major changes over the last thirtyyears.

Disease prevention, identificationof risk and preventive factors, evaluationof health initiatives, and quality treatmentshave been required and progressivelyreplaced by the concept of restorativedentistry (care). As in other health areas,the question is whether or not clinicaldata, with all the logistical and economicimplications that it poses, should remainthe cornerstone of the dental monitoringsystem. It is not a question of replacing theDMFT; at issue is its position and promi-nence in relation to other more responsiveindicators, for example questionnaire-based indicators.

Minorities and deprived groups in manyEuropean countries have a high level and/of untreated diseases

. Oral health is char-acterized by social inequalities in the faceof disease and patient management. InFrance, 40% of 12-year olds have no DMFtooth; most other children fall in the rangeof 1 to 4 DMFT teeth. In contrast, 10.8%of all children have a DMF greater than 4teeth. In the trend observed in Europeancountries with good demography, 1/3 ofthe children have about 80% of DMFteeth, and 1/4 of the children have about65% of DMF teeth. And 10% of the chil-dren have about 40% of DMFT teeth.Therefore, the “traditional” preventivemethods evidenced in most cases exhibitlimitations among population groups witha high risk of tooth decay groups moreoverpoorly identified on the epidemiologicallevel. These populations at high risk fortooth decay – perhaps not their only riskfactor – remain on dental health chartsrecorded in the years 1965, the same pop-ulations for whom treatment is apparentlydifficult to come by.The failure of prevention is also the failureof the dental health care system. It is there-fore necessary to identify alternativeapproaches if we wish to make progress.Getting rid of inequalities should be the pri-mary purpose of the health system, whencethe suggestion of innovative, integratedapproaches. Serious thought must be givento the type of indicators for this programme,its strategies, and intended results.

Increasing cost which represents 4-8% ofthe total expenses in health.

The oralhealth care system in Europe has eco-nomic significance, thus the industrializedcountries’ clear policy, despite the dispar-ities observed in health care expenses.Data for the OECD is explicit.

10

Dental expenditures represent 3.8 to 8%of all health care expenditures. For theeight OECD countries used in this exam-ple, average expenditures for dental care

per individual increased by 1.5 between1990 and 2000, with variable differencesaccording to the country.

In 2000, expenditures for dental care rep-resented an average of 0.5% of the GDP,or approximately 1/17

th

of overall healthcare expenditures. Germany spent propor-tionally the most for its oral health: 0.8%

of the GDP. France falls in the middle with9.3% of the GDP devoted to health careand 0.5% reserved for dental care. Finland(0.4%) and the Netherlands (0.3%) havethe smallest expenditures. A comparative

Figure 1. Health and Oral health care expenditures 2000 (% GNP) for 8 OECD countries

Source: Software Eco-Santé OECD 2003.

Years 2000

0,4

0,5

0,3

0,5

0,7

0,5

0,8

0,6

0 5 10 15

Oral Health

Health

6,7%

13,1%

10,6%

9,3%

9,2%

8,9%

8,6%

7,6%

USA

Germany

France

Canada

Australia

Netherlands

Japon

Finland

Figure 2. Oral health care expenditures in 1990 and 2000 per capita for 8 OECD countries

Source: Software Eco-Santé OECD 2003

Allemagne Etats-Unis

Canada Japon France Australie Finlande Pays-Bas

19902000

250

200

150

100

50

0


11

analysis of European oral health care sys-tems therefore seems of the utmost impor-tance. The operational goal via the imple-mentation of a regional monitoring systembased on economic-type health indicatorswould increase their effectiveness, theirperformances, and improve cost/effi-ciency.

A professional demography in transition.

245 169 dentists, 13 295 dental hygienistswork in 1998 the European Union andEEA. The dental profession has an impacton employment in advanced health care.The majority of European countries ques-tion policy choices on dentistry pro-grammes because the profession is sensi-tive to the economic and healthenvironment. Many issues give rise toquestions. The most important questionsfor planning are: what type of oral healthprofessionals for what type of practice;what type of dentist for what type of prac-tice; and how many dentists per capita inthe medium term.These questions are principally related tothe items in the following list – which isnot exhaustive –: (1) the observed changein the state of dental health among popu-lations; (2) the evolution of techniques; (3)the development of behaviours andexpectations among populations regard-ing the dental health care system; (4) theannounced coordination of Europeanstudies for the Licence Master Doctorate;(5) the spread of dental hygienists; (6) thedemographic balance linked to retire-ment; (7) the economic impact of healthinsurance reforms; (8) health care as a ser-vice; (9) the expansion of the Union, etc.Add to that the problem of declining qual-ity of care, a hypothesis advanced in cer-tain countries, and related, among otherthings, to (1) the growth of increasingly

open professional competition within afree market; (2) the trend of growing oper-ating costs becoming more and more sig-nificant and hurting the practitioners’ prof-itability; (3) the impending deregulation ofsocial welfare systems; (4) access to pri-vate dental training leading to non-con-trolled professional demographic, etc.In the interest of the populations and soci-ety at large, which is entitled to a qualityundertaking of responsibility, the area ofprofessional demographic control repre-sents an important European issue. Thefirst stage of this approach is a properqualitative and quantitative assessment ofthe practices – which is presently lacking –,an assessment that should encourage aidin the decision for planning services. Thatbeing said, “Quality of the information inoral health is affected by the insufficientuse of available data for planning, imple-mentation, service management and eval-uation and the inadequate quality of dataproduced”.The insufficient available data and the sig-nificant decrease in representative studiesThe international epidemiological moni-toring of oral health is a relatively recentinitiative. The Epidemiological and Infor-mative System (EIS) of the WHO OralHealth Programme started in 1969 withthe establishment of the Global Oral DataBank. As a general rule, evaluation of oralhealth currently relies on the analysis of alarge number of studies. A total of 1,890scientifically validated studies in 2000was contained in the WHO data base butthe fact that these surveys have more localor regional rather than national represen-tativeness somewhat limits their impact.In Europe, the small amount of representa-tive data on the status of oral healthamong populations is targeted, when it

12

exists, on DMFT indicators and 12-yearolds. Data has significantly declined thepast 10 years. Only rarely is data part of ahealth monitoring methodology. Fewcountries in Western Europe have estab-lished a data collection system at thenational level: only Great Britain has sec-ular epidemiological data on the preva-lence of caries in young adults. Swedenand the other Scandinavian countries usedcountry council reports to the NationalBoard of Health and Welfare through thepublic dental service. No representativedata on the status of the population’s oralhealth existed in France before 1987 inwhich year the first two national epidemi-ological studies were conducted to assessthe oral health of children of six, nine andtwelve years of age.The WHO data bank is based on specificmethods that are recommended in oralhealth epidemiology, themselves resultingfrom basic epidemiological methods. Itsmethodological specificity is mainlyrelated to the definition of the populationthat should be studied, sampling methods,indicators and monitoring index of decay,standardization of findings presentation. Itseems that synthesis international articlesare the main sources used to proceed to astate analysis of trends; they can be foundin the WHO Data Bank.A critical analysis of the methodologicalcriteria used in “Materials, Methods, andResults”, rubrics of the international scien-tific literature on cross-section studies bycountry at equal age, published for theoral health period 1986-1996 has under-lined. New and complementary trendsshould be recommended so as to improvethe production of higher quality informa-tion in oral health epidemiology. Stan-dardized procedures should be developed

and used. The expansion of oral epidemi-ology during the 1970s overcame theobvious shortcomings in terms of knowl-edge about the oral health status of popu-lations even though developed actionsmainly targeted school children. Col-lected data favoured cross-section studieswith no repetitive character since theiraim was not to target the cohorts.At this stage of the produced informationanalysis, research and development per-spectives should focus on the setting up ofa health monitoring and recording systemand furthermore, on respecting the rules ofresults dissemination that should lie withina benchmark methodological framework.The analysis of the publications showedweaknesses in the evaluation of oralhealth trends: weaknesses in terms ofmethodology, quality control, and presen-tation of results. The interpretation andconclusions in public oral health aretherefore limited. New or complementarymeasures should be taken in order toimprove the quality of medical informa-tion in oral health epidemiology.

The profusion of internationally indicatorscomplicates the national selection of indi-cators and may lead to costly and unnec-essary monitoring efforts.

Analysis of theliterature highlights the profusion ofrecently available Indicators. These indi-cators stem from research developed inthe health field, within the framework ofinternational oral health programmes(ICSII, Biomed, Oratel, etc.) and nationaland even local studies with very limitedimpact. “Improvements” are regularly sug-gested to improve epidemiological knowl-edge about the state of dental and peri-odontal health among the populations.But these new types of indicators havegenerally dealt with quality of life, deter-


13

minants that include preventive factors,risk factors, and socio-demographic fac-tors. Curiously, the indicators targetinghealth services and the health economyare underrepresented.The many studies and publications avail-able in this area create confusion aboutthe selection and hierarchy of publichealth indicators. Boundaries are vaguebetween the presentation and utilisation ofclinical research indicators, foundationalresearch indicators, and public healthindicators, which are related to timelyresearch projects without real operationaldevelopment and without concrete appli-cation to coordinate European monitor-ing.Therefore the disparity between the qual-ity and the quantity of available indicatorsmust be emphasized. Oral health has tra-ditionally been defined in terms of dis-ease. The complexity of the indicatorsrequired to characterize oral health isundoubtedly influenced by the complex-ity of this discipline. Oral health is stronglyage related and there is often an increasein severity and prevalence with increasedage and leads no doubt to an oral healthspread of indicators. Yet the prioritiesgiven to clinical indicators do not cur-rently rank among the most important rec-ommendations advocated for develop-ment by European and/or internationalauthorities in the area of monitoring non-contagious diseases. To this end, a newtype of indicators will facilitate furtherpromotion of oral health and non commu-nicable disease surveillance in Europe tocollect information, to monitor changes,to assess the effectiveness of the serviceand to plan oral health services.

In this context, the scopes and purpose ofthe European Global Oral Health Indica-tors Development Project for 2003-2004are to support the exchange of expecta-tions and experiences among experts oforal health statistics and their audience,policy makers in particular. It is also toconduct a systematic review and to out-line a process for identifying a set of coreindicators for oral health that will helpprofessionals to promote and improve theglobal oral health promotion, quality ofcare and surveillance of people in Europe.

Overall objective were listed i.e. to sup-port European Member States in theirefforts to reduce the toll of morbidity, dis-ability related to oral health diseases andespecially:• To strengthen the ability at the local,

national, regional levels to measure,compare and determine the effects oforal health services and use ofresources on oral health;

• To identify indicators of oral health(problems, determinant and risk factorsrelated to lifestyle) of critical oral healthcare, its quality of care and of essentialhealth resources;

• To identify the types of data generationand management problems within thehealth information system.

Beyond the actual scientific aspects of theresearch itself, such European projects areto develop collaborative work among theEuropean country teams to set up network-ing processes, habits and culture. In addi-tion, the project is an integration and fur-ther development of a large number ofongoing oral health projects in differentfields in Europe and at WHO. In particularin Europe, it will use the development of setof specific and generic cost and health indi-

14

cators, i.e. the “Oral health project” (DGXIII, 1993/95; DG XIII 1997/98), the“Biomed Programme” (DG XII 1994/1998);just as the “Oratel Telematic Systems forQuality Insurance in Oral Health Care”(CEC Project A 2029), WHO RegionalOffice for Europe (1992). In the same way,we can advance the “Quality of CareDevelopment Programme in Oral Health”,WHO Regional Office for Europe (1999).The organization of the project is organ-ised around a steering committee group,

representative of the 15 countries of theEuropean Union and working in collabo-ration with specific partners

(Table 1)

.Agenda, methods and work plan proposedin the two years processes were outlined.The objective of the 2003 year, first periodof activity of the project was through aEuropean consultation and an EU/Work-shop on Oral Health Statistics to conducta systematic review and to outline a pro-cess for identifying a set of core indicatorsfor oral health that will help professionals

Table 3. The European Global Oral Health Indicators Development Project Organization

European Official National Partners

Austria:

University of Graz (Dr G. Wimmer)

Belgium:

University of Louvain (Pr. JP Vannieuwenhuysen)

Denmark:

University of Copenhagen

(Pr P.E. Petersen)

Finland:

Ministry of Health (Dr. A. Nordblad)

France:

University of Lyon (Pr. D. Bourgeois)

Germany:

University of Dresden (Pr. T Hoffmann)

Greece:

Technology Institute, Athens

Ireland:

University of Cork (Pr. D. O’Mullane)

Italy:

University of Milan (Pr L. Strohmenger)

Norway:

University of Bergen (Dr E. Skaret)

Netherlands:

University of Amsterdam (Dr JSJ Veerkamp)

Portugal:

University of Lisbon (Pr. C. Mexia de Almeida)

Spain:

University of Grenade (Pr. Loddra Calvo)

Sweden:

Ministry of Health (Dr C. Källestål)

United Kingdom:

University of Glasgow (Pr D. Kinane)

Associate Partners

European Organization

• European Association of Dental Public Health• Council of European Chief Dental Officers• European Federation of Periodontology

UE Candidate Countries

• Latvia• Leetonia• Republic Czech

World Health Organization• Oral Health Programme, Geneva, Switzerland• Surveillance Noncommunicable Diseases and Dental Health, Geneva, Switzerland


15

to promote and improve the global oralhealth promotion, quality of care and sur-veillance of people in Europe.The also goal of this first year of the Euro-pean Global Oral Health IndicatorsDevelopment Project is to initiate at theconclusion of the first meeting, Lyon Sep-tember, the long list of indicators, back-ground document for the establishment ofthe major indicators.The expected results, at the end of the twoyears process should be:• To promote of systematic identification

and technical specifications of oralhealth indicators through the use of anoral health outcome framework includ-ing information on the level of develop-ment of existing indicators and issueswhere indicators are lacking andrequire research

• To facilitate comparisons of indicatordata by promoting standardization ofindicators;

• To improve the capacity of area healthservices to monitor their oral healthimprovement activities in a standard-ized manner in the longer term

• To facilitate, in the longer term, servicespecifications across area health ser-vices with a view to maintaining andimproving performance;

• To enhance the capacity to analyse thesocial, economic, behavioural andpolitical determinants with particularreference to poor and disadvantagedpopulations.

The object of this current document setrelates more specifically to the firstdomain of the project.

Documents of reference

•

Programme of Community action in the field of public health (1998-2002).

htpp://europa.eu.int/comm./health/ph_projects/monitoring_projects_en.htm

htpp://europa.eu.int/comm./health/ph_projects/monitoring_projects_full_listing_en.htm

•

Summary record of meeting of health monitoring project co-ordinators held in Luxembourg on 18-20 March 2003.htpp://europa.eu.int/comm/health/ph_overview/previous_ programme/previous_programme_en.htm

•

Draft Mandate – Network of competent authorities in the Members States responsible for health informationand knowledge

htpp://europa.eu.int/comm/health/ph_overview/previous_programme/previous_programme_en.htm

•

Opportunity for further health gains – Chapter 9 – In: The state of health in the European Community in theyear 2000. Final report

htpp://europa.eu.int/comm/health/ph_projects/2001/monitoring/monitoring_project_2001_full_en.htm#8

17

Conceptual Positioning within International Experience

Indicators in health: The WHO Stepwise approach, a framework for surveillance

Ruth Bonita

Cross-country applicability of social survey indicators: the contribution of theSecond International Collaborative Study on Oral Health Outcomes, the ICSII


Basic indicators for development of quality of oral health systems in Europe –the approach of the World Health Organization

Poul Erik Petersen

Efficiency in Oral Health Care. The Evaluation of Oral Health Systems in Europe

Helen Whelton

Dental Manpower: Specific situation in Spain

Manuel Bravo, Juan Carlos Llodra and Frederico Simón

19

Indicators in Health.The WHO Stepwise approach – a framework for surveillance

Ruth Bonita

1

Introduction

Good quality health information is essen-tial for planning and implementing healthpolicy in all countries. Surveillance pro-vides ongoing (continuous or periodic)collection, analysis and interpretation ofpopulation health data and the timely dis-semination of this data to users. Properlyconducted, surveillance ensures thatcountries have the information that theyneed to fight an epidemic now or planstrategies to prevent disease and adversehealth events in the future. A systematicapproach to data collection helps coun-tries to monitor and evaluate emergingdisease patterns and trends. The goal is toassist governments and health profession-als to formulate policies and programmesto prevent disease and to measure theprogress, impact, and efficacy of efforts tocontrol diseases that are already effectingtheir populations.

Surveillance strategies

Surveillance of noncommunicable (chronic)diseases (NCD) such as cancer and heartdisease, and for the purposes of this meet-ing, oral health status, usually requires a sus-tained effort over a long period of time. Thepolicy implications of such informationmeans that, in comparison to communica-ble diseases, which require a response inreal time, a planned response is possible.The link between the data and action(health policies and programs) is key

(Figure1)

.

Figure 1. Characteristics of a Surveillance system

Influence

evaluate

HealthInformation

Systems

Research SurveillanceHealth policies

and Programmes

1. Director, NCD Surveillance, World Health Organisation, Geneva, Switzerland. Based on a presentation at the Meeting on Health SANCO Monitoring Programme in the imple-mentation of the European Oral Health Indicators, Lyon, France 4-5 September 2003.

20

However, gathering data on morbidity ofspecific conditions and health states,including oral health, offers particularchallenges. The oral health sector hasbeen well served by standardised surveysfor Adults and Children over the past fewdecades using specific age groups with thestorage of that data in a databank facilitat-ing comparisons between countries andtrends within countries.The attempt by the members of meeting torevisit the Oral Health Indicators for sur-veillance within the European setting is anadmirable one. It is similar to the processrecently undertaken at the World HealthOrganisation (WHO) for obtaining popu-lation level data in risk factors for NCDs,including oral health. The many and var-ied surveys and methodologies availablehave left countries in a quandary as tohow best to establish methods to ensurethat reliable and valid results would beachieved in measuring some of the majordiseases and some of their associated riskfactors.The WHO surveillance program wascharged with developing an approach toNCD surveillance which was globally rel-evant, locally useful, and sufficiently flex-ible to allow countries to contribute at aminimum level by the inclusion of a fewkey, standardised indicators. Reaching aconsensus on what this “minimum level”or “core” level, is, in itself, is an importantexercise.

Rationale for Surveillance of NCD risk factors

Surveillance of NCD has been neglectedin modern public health. The populationdistribution of the major common risk

factors for chronic diseases is the keyinformation required by countries forplanning primary prevention programmes.Because of the relatively long time framebetween exposure to a causal agentand disease, monitoring and surveillanceof chronic diseases can be a costlyexercise involving disease registers andlegislation to ensure disease reporting.For this reason, most of the focus for sur-veillance of chronic disease involves sur-veillance of modifiable risk factors fordisease.The priority for surveillance of noncom-municable disease risk factors are thosewhich have the highest avoidable burdenof disease, can be changed through pri-mary prevention, and are easily measuredin populations. This common risk factorapproach is a rational basis for promotingoral health as well.

Surveillance of risk factors

Surveillance of noncommunicable diseaserisk factors is becoming increasinglyimportant to many countries as they try tocontrol rising health care costs for an age-ing population. The need for reliable,country-level information on the preva-lence of risk factors for chronic disease isobvious if we are to avoid the predictedhigh burden of these diseases throughtimely population-level interventions.Unfortunately, country-level data on com-mon, measurable chronic disease risk fac-tors are sparse. This deficit seriously hin-ders efforts to combat the emergingepidemics of noncommunicable diseasesespecially in low and middle incomecountries.

Indicators in Health. The WHO Stepwise approach

21

Addressing data gaps and deficiencies

There are limitations to current existingNCD risk factor data collections. It is diffi-cult to compare survey data across coun-tries. Even within a country, where trenddata are available, this data may not becomparable. Part of the problem is the useof different survey instruments, differentmeasurement methods and different crite-ria for a clinical outcome. These problemscan be solved by agreeing to standardisedsurvey instruments and agreed upon indi-cators, definitions, methods, and samplesize.Surveillance underpins public healthaction and health promotion activities.

The WHO NCD global surveillance strat-egy includes several components:• Identification and description of the

common NCD risk factors, using rec-ommended WHO definitions;

• A coordinated approach to conductingsurveillance of risk factors that upholdsscientific principles and that is suffi-ciently flexible to meet local andregional needs;

• Technical materials and tools, includ-ing training, to support the implementa-tion of surveillance;

• Effective communication strategies forproviding data to those involved in thedesign of policies and intervention pro-grammes, potential funders, and thegeneral public.

Two new WHO surveillance tools

WHO has developed two major new toolsfor NVD surveillance: the STEPwise

approach to Surveillance (STEPS) and theWHO Global NCD InfoBase. Both haverelevance to oral health data already col-lected as well as the potential for obtain-ing new data on core oral health indica-tors by adding onto ongoing country levelsurveys or by their inclusion in surveyssuch as the World Health Survey.

The WHO STEPwise approach to Surveillance

1

The STEPwise approach, allows for thedevelopment of an increasingly compre-hensive surveillance system, dependingon local needs and resources. By using thesame standardized questions and proto-cols, all countries can use the informationnot only for monitoring within-countrytrends, but also for between-country com-parisons. The questionnaires and methodsrecommended must therefore be relativelysimple.The assessment methods selected forSTEPS for risk factors associated with NCDwere chosen on the basis of their ability toprovide trends in summary measures ofpopulation health. Hence they may notnecessarily give a complete picture ofeach risk factor. Each country needs todetermine which additional modules atthe population level are appropriate andwhat can be accomplished in the contextof an ongoing surveillance system.For surveillance to be sustainable, theSTEPwise approach advocates that smallamounts of good quality data are morevaluable than large amounts of poor qual-ity data, or no data at all.

1. See http://www.who.int.ncd_surveillance

22

The conceptual framework underlyingSTEPS is shown figure 2.The key feature is the distinction betweenthe

different levels of risk-factor assess-ment:

• information by questionnaire (Step 1),• physical measurements (Step 2), or

• blood samples for biochemical analy-ses (Step 3);

and the three modules involved indescribing each risk factor:

• core• expanded core, and• optional.

Figure 2.

Table 1. STEPS approach to risk factor assessment

Levels

ModulesStep 1:

Questionnaire-basedStep 2: Physicalmeasurements

Step 3:Biochemical analyses

Core

Socio-economic and demographic variables, tobacco, alcohol, physical nutrition

Measured weight and height, waist girth, blood

Fasting blood sugar, total cholesterol pressure inactivity,

Expanded core

Dietary patterns, education, household indicators

Hip girth HDL-cholesterol, triglycerides

Optional (examples)

Other health-related behaviours,

oral health

, disability, injury etc.

Timed walk, pedometer,skinfold pulse rate

Oral glucose tolerance test, urine examination thickness,


23

Step 1 – Questionnaire-based assessment

A Step 1 study is based on self-reportedinformation. The core module of Step 1contains as markers of current and futurehealth status socio-economic data, dataon tobacco and alcohol use, some mea-surements of nutritional status and physi-cal inactivity. Standard WHO definitionsfor measuring the prevalence of tobaccouse and alcohol consumption (9) andinternationally devised measures of physi-cal activity are recommended Oral healthindicators lend themselves to inclusion atStep 1 as an optional module.

Step 2 – Questionnaires and physical measurements

A Step 2 study includes as a minimum theStep 1 core module and

adds

simple phys-ical measurements such as blood pressure,height, weight and waist circumference.Step 1 and Step 2 are desirable and appro-priate for most countries.

Step 3 – Questionnaires, physical measurements and biochemical assessment

A Step 3 study

incorporates as a minimumthe core modules from Steps 1 and 2 andadds measurements obtained from bloodsamples. While most countries can man-age Step 1 and 2 in a field setting, the addi-tional information at Step 3 is of a bio-chemical nature and is therefore notrecommended by WHO in less well-resourced settings unless low-cost tech-nology is used.

Tailoring STEPS to suit local needs

One of the greatest challenges in develop-ing WHO STEPS has been to achieve abalance between ensuring standardizedtools and methods, and flexibility for usein a variety of country situations and set-tings. STEPS allows all countries to con-tribute to improving global informationabout trends in key measures of health.Expansion of the basic core questions ispossible in settings where resources andlocal surveillance needs allow a morecomprehensive assessment of these keyrisk factors. For both modules, core andexpanded core, assessment guidelines andstandard questionnaires are provided.Optional modules can also be added atStep 1 to include additional data on riskand protective behaviours, for exampleinformation on oral health status andhealth services use. The key recommenda-tion is a limited set of key indicators forsurveillance. Within the selected corevariables, choices must be made whichdistinguish between surveillance purposesand research purposes. For surveillance tobe sustainable, the cost of collection ofdata as well as its analysis, interpretationand use must be kept in mind when plan-ning the implementation of STEPS.

Tailoring STEPS to include optional modules: oral health

The STEPS framework allows for the addi-tion of add-on modules – intentionalinjury, unintentional injury, mentalhealth, and oral health are all good exam-ples. While most of these are Step 1 varia-bles (by questionnaire), oral health lendsitself to Step 2 (physical examination ofthe oral cavity) as well. In order for coun-

24

tries to ensure that the additional modulesare not burdensome, the challenge is toidentify – and agree upon – four or five keyindicators for oral health. The WorldHealth Survey conducted in 72 countriesduring 2003 offers a set of standard ques-tions from which a number of key indica-tors can be derived.

Expanded

indicators within the STEPwiseframework are also possible and could, forexample, refer to use of dental services, ora measure of the impact of a preventivehealth program.

The WHO Global NCD InfoBase

The second major surveillance tool is theWHO Global NCD InfoBase

1

. In order topredict the future burden of chronic dis-

ease in populations and also for identify-ing potential interventions to reduce thefuture burden, data collection and report-ing standards are needed to ensure thatNCD data can be used effectively toinform prevention and control activitiesfor health. This new WHO tool is nowbeing used to help set data standards forNCDs and their risk factors.

Much time and effort has gone into decid-ing which type of information is most use-ful for surveillance of noncommunicabledisease risk factors. Collection and storageof data has been limited to that which isstrictly relevant to outcomes. The indica-tors chosen must reflect those that cause alarge burden in the population, can bechanged through primary intervention,and are easily measured in populations.The starting point was the collation anddisplay of data on the major NCD risk fac-tors which have been identified by theWorld Health Report 2002 and which arebeing collected as part of the STEPSapproach mentioned above. The dataentered comes from a range of sourcesincluding published reports or ministry ofhealth reports or unpublished reports orwherever. The vision was to bring togetherin one relational data base, existing coun-try level data stratified by age and sex,with complete source and survey informa-tion and each record linked back to itssource, a necessity when the collection ofsuch data involves so many different pro-tocols and definitions.

The first report, for example, the SURF 1Report - presents the most recent nation-

Oral Health Care Questions from the World

Health Survey

a

1

During the last 12 months, did you have anyproblems with your mouth and/or teeth?

2

During the last 12 months, did you receiveany medical care or treatment from a dentistor other oral health specialist for this problemwith your mouth and/or teeth

3

What types of care or treatment did youreceive for this problem with your mouth and/or teeth?

Probe for all types of care or treatment.Record in questions all types mentioned.– Medication– Dental work/oral surgery– Dentures or bridges– Information or counselling on dental care/oral hygiene– Other oral treatment

4

Have you lost all of your natural teeth?

a. http://www.who.int/whs/P/instrumentandrel 8293.html

1. The data entry tool in a standard format and search and display functions are now on-line atwww.who.int/ncd_surveillance/infobase/en.


25

ally representative data for 8 risk factors. Itdisplays the prevalence, and/or the meanvalues by age and sex, and a measure ofthe uncertainty of the estimates. Anaccompanying CD ROM contains data for170 countries, 50 000 data points, about2 000 sources. In this sense it is a richsource of currently available informationfor many countries. Identifying country-level data and assessing its validity is thefirst step in developing better quality NCDdata collections. The second step is theharmonisation of existing data by develop-ing models to derive best estimates for anygiven risk factor or health state for eachcountry, based on the amalgamation ofthe existing data. The InfoBase demon-strates how to use the assembled data toproduce comparable, country estimatesfor NCD risk factors and diseases. Forexample, the Oral Health Indicators cho-sen, in consultation with the Oral Healthprogram within the NoncommunicableDisease and Mental Health cluster,include the following:• Decayed, missing and filled teeth;• Edentualism, and• Periodontal disease.

Disease specific modules are currentlybeing added to the Global NCD InfoBase.It also has an Oral Health componentwhich helps to identify a country’sstrengths in oral health data collection andalso its gaps and deficiencies. Ultimately,the aim is to drive the sustainable collec-tion of good quality risk factor data andpromote the establishment of surveillancesystems as an alternative to costly ad hoc“one time only” surveys which are oftendesigned without consideration to thesample size required to provide robustestimates by age groups and sex.

Partnerships for the future

The SANCO Monitoring Programme facesa major challenge in streamlining com-plex and overlapping monitoring systemsin the implementation of European OralHealth Indicators. The WHO offers twotools to encourage the collection of stan-dardised data and the collation and dis-play of this data in a manner which willallow measures of the changing oralhealth status in populations. There iswidespread recognition of the need fororal health programmes to be developedand integrated with other populationbased health programs. A core set of OralHealth Indicators for use in a wide rangeof countries is best suited in the context ofthe surveillance of other population mark-ers of risk, especially those common riskfactors which impinge on oral health. Inreaching consensus and through offeringtechnical support and leadership, the solu-tion will suffice not only for Europeancountries, but also for developing coun-tries who face enormous challenges inmaintaining sustainable surveillance sys-tems.Above all, oral health professionals have akey role in forging partnerships with awide range of agencies and professionalsto ensure that improvements in oral healthare achieved in the context of policies andprograms which are directed at an inte-grated approach. The same benefits canbe achieved by the integration of oralhealth indicators in new efforts to securereliable and comparable data for measur-ing trends in population health status. Thismeeting to develop a set of Oral HealthIndicators for the European region is animportant step in the right direction.

26

Cross-country applicability of social survey indicators: the contribution of the Second International Collaborative Study on Oral Health Outcomes, the ICSII


1

The broadening of oral health epidemiology

A major contribution, if not “the” majorcontribution of the ICS to oral publichealth is to have rootened a holistic ap-proach to oral health in the field of inter-national research. It is with the first ICSstudy in the 70s, that the traditional modelof oral epidemiology restricted to clinicalobservation, expanded dramatically to in-clude sociological studies and consider-ation of the entire oral health and healthcare systems. When ICS commenced inthe mid to late 1970s, it was unique in re-lating oral health clinical and sociologicaldata within and across cultures. Very fewgeneral health studies had been performedcross-nationally and none had made theclinical link at individual level. In an effortto better capture oral health determinants,the social interviews and the clinical ex-aminations were conducted on the

same

persons in each of the age groups of thestudy samples. This is another specific fea-ture of the ICS approach which, to our

knowledge, has not been replicated sincein any other Oral Health Survey of that di-mension. Even by the commencement ofICSII -around 1990-, few cross-nationaloral health or general health studies hadbeen conducted, thus leaving wide andtheoretical gaps. The wide-ranging social,political, economic and oral health caresystems from ICSII study sites provided anexcellent opportunity for each country tolearn from other countries (a practical goalof the study), and for researchers to findways to generalize the findings of singlecountry studies to other countries (the the-oretical goal).

Main descriptive aspects of the ICS series

The studies were initiated and conductedby the World Health Organisation in col-laboration with the Public Health Serviceof the United States (USPHS) and the Na-tional Institute of Dental Research (NIDR,now renamed NIDCR).ICS I took place from 1973 to 1981, in 10different sites in 9 countries spread over 4

1. EGOHID Coordinator, University of Lyon, France. Former WHO-ICSII Programme manager.

Cross-country applicability of social survey indicators

27

continents: the USA, Canada, Australia,New-Zealand, Japan, Norway, Ireland,Poland and the Federal Republic of Ger-many. The ICS I report was published in1985.About 10 years later, some countries fac-ing dramatic changes in their economic,political and health situation were willingto replicate the study in order to better ad-just their Oral Health Care system andhealth-related legislation. As part of itsmission, WHO has major interest in docu-menting epidemiological trends and fur-ther explore oral health determinants, twokey research dimensions of the ICSs. In theICS II WHO had the same scientific USpartners and this time, the Centre forHealth and Administration Studies of theUniversity of Chicago (CHAS) as part ofthe coordinating team and to whom thesocial surveys were subcontracted.ICSII was launched in an internationalmeeting held at WHO in 1988 with partic-ipating countries representatives. Coun-tries involved were: Poland, Germany,France and Latvia and outside the Europe-an continent: Japan, New-Zealand andthree sites in the USA. It is interesting tonote that more than half of the countrieswere in Europe and that a broad sample ofhealth care systems ranging from entirelyprivate to entirely public was offered forstudy comparisons.

Research objectives

ICSII established three major researchgoals. The first was to describe each of thestudy sites according to (1) oral health out-comes: oral health behaviour, oral healthstatus and oral quality of life, (2) socialgroup differences in oral health outcomes,and differences between individuals in

each of the oral health outcomes. For all ofthese dimensions, the sites were com-pared to gain a better understanding of thestatus of each site. The second goal was toinvestigate how the socio-environmentaland oral health care system characteristicsof the various sites were related to (1) dif-ferences in the status of their oral healthoutcomes (2) differences in the magnitudeof gaps between social groups in theseoutcomes and (3) differences in the ex-planatory factors. The final goal was to testwhether certain explanations for the threesets of oral health outcomes derived fromprevious single country studies could begeneralized to all sites in the study. Inpractical terms ICSII was aiming at de-scribing the oral care system and the oralhealth outcomes in each country, analys-ing the adequacy of the care system to re-spond to needs and demand of thepopulation, providing cross-country com-parisons so that public health decisionmakers and politicians could benefit fromother countries experiences.

The ICS II theoretical model

A theoretical model was developed. It wasused as a conceptual and practical tool inthe research design, the development ofthe survey instruments, and the analyticalprocess.Although several theoretical models hadbeen developed to explain determinantsof oral health behaviour and oral healthstatus, at the time of ICS II, they did not in-corporate all three oral health outcomes.The factors affecting the oral health of aperson can be found at individual leveland at system level. The model postulatesthat individual oral health behaviour (in-cluding oral hygiene practices and oral

28

health service utilization) as the intermedi-ate outcome variables is affected by his orher predisposing and enabling character-istics. In other words, characteristics suchas sex, education, occupation, health be-liefs predispose an individual to engage ornot, in certain oral health behaviour,while enabling variables such as income,residence, having or not having a usualsource of oral health care, represent con-ditions that might facilitate or impede theindividual practice of such behaviours.These personal characteristics are influ-enced by the system as a whole. The mod-el also postulates that an individual’scharacteristics and oral health behaviouraffect his or her oral health status, as mea-sured mainly by dentition and periodontalstatus. As the model indicates, both per-sonal characteristics and oral health be-haviour operate under the influence of thesystem-level factors. Finally the modelpostulates that an individual’s quality oflife is determined directly or indirectly byhis or her personal characteristics, oralhealth behaviour and oral health status, allof which are influenced by the system-level factors.The impact of the system-and individual-level factors on an individual’s oral healthbehaviour, oral health status and quality oflife has been tested in all sites as part of thestudy hypotheses.

Major methodological and conceptual outcomes

Twenty-five years of ICS studies havehighlighted many important findingswhich have had implication in the reorga-nization of oral health care systems. Espe-cially relevant to the reflexion on thestandardisation of oral health research in

Europe are some aspects of the method-ological developments provided by ICS.ICS II has provided the research communi-ty with a set of data collection instrumentson system characteristics, on oral healthstatus, on social surveys including healthbeliefs, behaviour, and quality of life in re-lation to oral health. All of them have beendesigned, tested, used in various settings,practical conditions, cultural and politicalcontext. Methods for calibration of exam-iners, adjustment of instruments to localconstraints, translation while keeping theconceptual content in different cultures,ensuring cross-country comparability andits limits, all these have been developed,used, tested.A major result relates to the validation ofquality of life as the ultimate outcome ofany oral health care system.

“...dental re-search has been dominated by the mea-surement and study of two diseases whichhave coloured public health perceptionfor the past 100 years. The quality of lifedimension indicates that the scope of oralhealth is much broader and thus, it is im-perative that oral health research shouldexpand its spectrum to include that di-mension in its mainstream, with importanteffects on approaches to oral health

”(Chen et al. 1997). This recommendationquoted from the conclusive chapter of theICS II report is fully relevant six years laterand oral health related quality of life isnow widely accepted as an essential com-ponent of oral health research.Recalling some major ICS II findings, im-poses to mention the relationship betweenoral health and general health whichstates that “perceived general health isstrongly correlated with oral health.” Notto remain at the conceptual level, thisfinding leads to a strategic orientation for


29

the dental profession with a strong focuson high-risk groups and a broader role ofthe dental manpower as stated by Barmesin 1997 “

It is probable that a successfulsearch for the fundamental factors thatmust be remedied would resolve not onlymany oral health problems, but also abroad spectrum of health and welfare de-fects. At the same time, a broader role forthe profession as a strategic entry pointmay be found to intensify the cost-effec-tive promotion of health. Only then wouldthe phrase “general health and oral healthare inseparable have a real and operation-al meaning.”

Further research developments

The issue of data comparability is a majorchallenge of multi-country research. In theclinical field researchers are dealing withobservation of the physical body made bytrained professionals. Methods for calibra-tion of examiners and calculation of vari-ability have been developed, tested,applied for many decades; it is usually ac-cepted that for epidemiological purposesthe WHO pathfinder methodology shouldbe recommended.However, the problem is far more com-plex when dealing with socio-culturalvariables. Researchers are then manipulat-ing concepts, translated into words, ex-pressed in various languages. They are nolonger dealing with observation of clinicalconditions, questions are asked and an-swers recorded.A series of techniques and methods havebeen developed in ICSII in an effort tomaximise the accuracy and comparabilityof the information collected. For example,the original questionnaires in English havebeen translated into the site language,

then back into English, Inter cultural ad-justment of the survey instruments havebeen made to ensure the conceptualequivalence and to give space to culturalspecificity while keeping meaning consis-tency, coding system for each item to cat-egorize the information “universal” or“country-specific” have been used.However, neither the measurement prop-erties- i.e. validity and reliabilityof thequestionnaires, nor their international ap-plicability had been scientifically evaluat-ed.Further research has been developedsince, which partly fills in the gap of themethodological evaluation of the ICSII so-cial survey instruments. In 2002 in a thesispresented at the University of Nancy,France, several domains of the ICSII ques-tionnaires have been analysed for theirpsychometric properties: oral-health relat-ed beliefs, behaviours and quality of life aswell as all the questions relating to patientsatisfaction with oral health care (Tapsobaet al. 2000).All the above-mentioned domains wereanalysed using similar statistical methodsand provided similar results, therefore thispaper will restrict their description to theanalysis of the questionnaire on oralhealth related quality of life (ORHQOL).

The main dimensions of Oral Health related Quality of Life

Over recent years the concept of Oralhealth related quality of life has been in-troduced extending the assessment of oralhealth to include the social and psycho-logical impact of oral diseases on individ-uals. Oral health related quality of life hasbeen defined as a multidimensional con-cept including the following domains: sur-

30

vival of the individual (i.e. absence of oralcancer), absence of impairment, diseaseor symptoms, appropriate physical func-tioning associated with chewing and swal-lowing, and absence of pain ordiscomfort; emotional functioning associ-ated with smiling; social functioning asso-ciated with performance of normal roles;perceptions of excellent oral health; satis-faction with oral health; and no social orcultural disadvantage due to oral healthstatus. It has also been described as in-cluding self-perceived oral health statusand treatment needs; assessment s of oralpain or discomfort; the impact of diseaseon the mechanical functioning of the oralcavity (such as speaking or opening andclosing the mouth); ability to perform selfcare (for example brushing and flossing);psychological issues (such as social dis-comfort in conversation or concerns aboutappearance); and limitations on activitiesrelated to role (such as the ability to per-form work or other duties).As mentioned earlier, the development ofthe ICSII – ORQOL was based on the threemain dimensions of health- related qualityof life: physical symptoms, perception ofwell-being and functional capacity. Self-reported oral disease symptoms, percep-tion of oral well-being, and social andphysical functioning were the dimensionsadopted for use in the ICSII questionnairesat international level.

International validity and reliability of ICSII questionnaires

The first priority when developing a ques-tionnaire to assess quality of life across na-tions is to determine the extent to whichthe concepts and dimensions hypothe-sized are universal. A minimum require-

ment for international validity andreliability is a clear factor structure repli-cated across countries with the same itemsand comparable variance.The factorial structure of the question-naires was analysed using the informationcollected on adults (35-44) and children(12-13) in three ICSII sites: New-Zealand,Poland and Germany.The ORHQOL questionnaire for childrenwas self-administered at school. It com-prised 14 items categorized in three di-mensions: self-reported oral diseasesymptoms; perceived oral well-being andsocial and physical functioning. Eight di-chotomously scored items were designedto measure self-reported oral diseasesymptoms experienced in the year prior tothe interview: broken tooth, painful orbleeding gums when brushing or flossing,tooth pain when eating or drinking sweets,bad taste or bad breath. Two items mea-sured perceived oral well-being: per-ceived oral health rated on a five-pointscale (excellent, very good, good, poor,very poor) and satisfaction with the ap-pearance of the teeth on a similar scale.Four dichotomous items explored socialfunctioning (avoiding meeting others, ex-periencing jokes being made about one’steeth, avoiding laughing or smiling be-cause of unattractive teeth or gums) andphysical functioning (missing school be-cause of oral health problems).Three dimensions of ORHQOL were alsoexplored in the questionnaire for adults.The perceived oral well-being dimensioninclude two items: perceived oral healthrated on a 6-point Lickert scale (excellent,very good, good, fair, poor, very poor) andsatisfaction with the appearance of theteeth (very much, quite a bit, they look ok,not much, not at all). The self-reported


31

oral disease symptoms dimension includ-ed the same eight dichotomously scoreditems as for children. However, the socialand physical functioning dimensions dif-fered. The physical component includedtwo dichotomous items (usual activitieslimited because of oral pain or discomfort,and inability to chew hard food) and oneitem (trouble sleeping because of oral painor discomfort) with four possible answers(very often, fairly often, sometimes, never).The social component comprised twoitems assessed using a 4-point Lickertscale, avoid laughing or smiling becauseof unattractive teeth or gums and avoidconversation because of unattractive teethand gums or bad breath. Additional itemsfor edentulous adults were satisfactionwith the appearance of false teeth/den-tures (a 5-point scale ranging from verymuch to not at all) and four dichotomousitems related to problems with wearingdentures (talking clearly, eating, sorenessand fit).A detailed description of the statisticalanalysis can be found in the article refer-enced below. In summary, the factorstructure was examined using principalcomponent analysis, the reliability was as-sessed using Cronbach’s alpha coefficientfor measuring internal consistency and theCattell’s salient index was used to assessthe factor structure similarities acrosscountries.The inter factorial similarity was demon-strated in all three countries, the reliabilityof the questionnaires ranged from moder-ate to excellent depending on the dimen-sion and the country considered and apreliminary evidence of the cross-culturalstability of the ORHQOL questionnaireshas been established.

Building upon international experience

As mentioned previously, similar work hasbeen carried out on the other dimensionsof QOL in relation to oral health status,with similar results. Further research mightbe encouraged in this direction to sustainresearchers confidence in the ICS II meth-odological heritage.Whereas ICS was carried out as a consid-erable human, practical and economicalinvestment, a similar challenge could betaken up in Europe at a much lower cost intime, energy and consequently in financialterms. One way of reaching this objectiveis obviously to dramatically reduce thesurvey instruments and to identify a set ofminimal essential and universal indica-tors. The ICSII questionnaires for adultsand children are provided in

“ComparingOral Health Care Systems: a second inter-national collaborative study”

(Chen etal.1997).

The core questionnaire for adultsis attached, appendix 1. They were de-signed for international research purposesin an attempt to fill in mainly theoreticalgaps and to provide further research direc-tions. In this respect, the instruments havedemonstrated their adequacy and theirlimitations. One reasonable way in con-sidering the questionnaires for their reduc-tion might be to identify the most cross-sites robust variables as indicated in thefindings of the ICSII analysis (and similarlythe least robust variables internationally).ICSII results demonstrated some strongand systematic associations.These relationships observed repeatedly atICSII sites with a wide – spectrum of oralcare systems were found “conclusiveenough for identifying target populations,designing new programmes or redesigningold-programmes”. Special consideration

32

might be given to the following findings:females brush and floss more than males,residents of urban or more affluent com-munities brush and floss more than others,adults with higher education and incomebrush and floss more than others, thosewith a usual source of care visit oral healthproviders more than others, adults with ausual source of care have lower decayedto total teeth ratios, higher D componentsof DMFT are correlated with higher num-ber of symptoms reported and with poorperceived oral health, prevalence of fluo-rides in a community predicts lowerDMFT scores, perceived general health isstrongly correlated with oral health.Clearly, the issue of the standardisation oforal health information to be collectedthroughout the European Community callsfor the identification of a minimum set ofrobust, replicable indicators. Importantcriteria for the methods to be used aretheir feasibility and cost-effectiveness.Extensive research has been developed inthe European region in the last decades ofthe past Century, which added to the ICSseries, form the scientific experience onwhich new developments should bebased. The always present temptation toreinvent the wheels should be avoided.Whether we refer to ICS, ORATEL,BIOMED, many international researchprojects have been carried out offeringtheir results, methods and past experienceas a compendium of knowledge whichhas enriched the community of oral publichealth. Much can and should be learnedfrom what has been done in the past years.Building upon international experience isthe most reasonable, cost-effective andethical way to develop and implementnew oral health research projects in theEuropean Community.

References

Andersen RA. (1976). A framework for interna-tional comparisons of health services systems. In:Pflanz M, Schach E. eds.

Cross-national socio-medical research: concepts, methods, practice. Aseminar under the auspices of the ISA

. Stuttgart,George Thienne.

Arnljot HH, Barmes DE & Cohen LK. (1985)

Oral Health Care Systems: An International Col-laborative Study.

Quintessence, London.Barmes DE. The oral health challenge at the

dawn of the third millenium.

Br Dent J

1994; 177:387-390.

Barmes DE, Leclercq MH, Petersen PE. (1994).

Global oral health policies of the future.

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Blum H. (1973).

Planning for health, develop-ment, and application of social change theory

.New York, Huma Science Press.

Chen M., Andersen RM, Barmes DE, LeclercqMH. & Lyttle CS. (1997)

Comparing oral healthcare systems. A second international collabora-tive study.

Geneva: World Health Organisation.Cohen LK, Bailit HL, Barmes DE. International

collaborative study on oral health outcomes.

IntSociol.

1987; 2: 419-426.Leclercq MH, Barmes DE. International Collab-

orative Studies in oral heath: a practical illustra-tion of WHO research policy.

Int Dent J

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Tapsoba H, Deschamps JP, Leclercq MH. Fac-tor analytic study of two questionnaires measur-ing oral health-related quality of life amongchidldren and aduls in New-Zealand, Germanyand Poland.

Qual Life Res

. 2000; 9: 559-569World Health Organization. (1993).

Calibra-tion of examiners for the International Collabora-tive Study of Oral Health Outcomes (ICSII),

ORH/EIS/EPID.93.1


33

A

PPENDIX

1

International Collaborative Study of Oral Health Outcomes

WORLD HEALTH ORGANIZATION

Core Questionnaire for adults

Developed by the Center for Health and Administration StudiesThe University of Chicago – USA –

ORAL HEALTH STATUS AND HYGIENE

1. Would you describe your oral health asexcellent, very good, fair poor or very poor?2. How would you describe the health of yourteeth and gums? Is it excellent, very good, fair,poor or very poor?3. During the past twelve months, did yourteeth or gums cause any pain or discomfort?(yes, no, don’t know, no answer)4. During the past twelve months, has the painor discomfort of dental problems caused youlimit any of your usual activities? (yes, no, don’tknow, no answer)5. How many days during the past twelvemonths, have you had to limit your usual activ-ities because of the pain or discomfort fromdental problems? (enter number…)6. How often do you have trouble sleepingbecause of pain or discomfort from dentalproblems? (very often, fairly often, sometimes,never)7. How often do you avoid laughing or smilingbecause of unattractive teeth or gums? (veryoften, fairly often, sometimes, never)8. How often do you avoid conversationbecause of unattractive teeth or gums or badbreath? (very often, often, sometimes, never)9. Are you able to chew hard things, such ashard bread or apples? (yes, no)Please tell me if you have had any of the fol-lowing problems during the last twelvemonths: (answer modalities are “yes” “no”from 10 to 18)10. A broken or chipped tooth?11. Gums that hurt or bleed?

12. Sores on your tongue or on the inside oryour mouth or cheeks?13. A bad taste in your mouth or bad breath?14. Do you have any natural teeth at all?15. Gums that frequently bled when brushed orflossed?16 Teeth that hurt when you ate or drank hot orcold liquids or foods?17. Teeth that ached or throbbed?18. Teeth that hurt when you ate or dranksweet things?19. How much do you like the way your teethlook? (very much, quite a bit, they look ok, notmuch, not at all)If you had a dental examination tomorrow, doyou think the dentist would say to you:20. You need to brush your teeth better (yes,no)21. You need to have your teeth cleaned (yes,no)22. You need fillings (y, n)23. You need to have a tooth pulled (y, n)24. You need to have your teeth straighened (y, n)25. Your teeth are good, nothing is wrong (y, n)26. Do you b rush your teeth? (y, n, don’tknow)27.How do you usually brush your teeth? (5modalities for frequency)28. Do you use toothpaste containing fluoride?(y, n, don’t use toothpaste, don’t know whatfluoride is)29. Do you have any physical problems thatmake it difficult for you to brush your teethsuch as opening your mouth or moving yourhand? (y, n)

34

30. Apart from fluoride in toothpaste or in thewater supply, do you use fluoride in any otherway, that is in tablets or in a mouth wash? (y, n)31. Do you use dental floss on your teeth? (y,n, don’t know what that is, no answer)32. How often do you use dental floss on yourteeth? (six modalities for frequency)33. Do you have any physical problems thatmake it difficult for you to use dental floss suchas opening your mouth or moving your hand?(y, n)Do you use any of the following to clean thespaces between your teeth:34. Wooden toothpick? (y, n)35. “ “ ? (y, n)36. “ “ ? (y, n)37. How often do you eat something inbetween your main meals? (five modalities forfrequency)Yesterday, did you eat any of the followingfoods: (y, n)38. Bread?39. Sugar-coated cereal?40. Fresh fruits (apples, oranges)?41. Pastry, such as biscuits, cakes, pie, dough-nuts?42. Soft drinks, cola drinks, soda flow (exclud-ing diet cola)?43. Nuts, cheese?44. Jams or honey?45. Dried fruits such as raisins, figs, prunes?46. Chewing gum containing sugar?47. Candy?48. Do you smoke cigarettes?Do you use the following type of tobacco: (y, n)49. Chewing tobacco?50. Cigars?51. Pipes?52. Snuff?Now, I’d like to know how you feel about tak-ing care of your teeth. Do you “strongly agree”,“agree”, “disagree” or “strongly disagree” withthe following statements?53. Brushing teeth with a fluoride toothpastehelps prevent tooth decay.

54. Brushing teeth helps prevent gum prob-lems.55. Using dental floss does

not

help preventgum problems.56. Eating sweet foods

does not

cause toothdecay.57. Drinking fluoridated water helps preventtooth decay.58. Using fluoride is a harmless way of pre-venting tooth decay.59. Going to the dentist will keep me from hav-ing trouble with my teeth, gums or dentures.

DENTURES/FALSE TEETH

60. Do you have any false teeth or dentureswhich you can remove? (y, n)61. A partial denture? (y, n)62. A full upper denture? (y, n)64. Where did you get your last falseteeth/dentures? (five answer modalities forplace)65. How many years ago did you get your lastfalse teeth/dentures? (number of years…)When you wear your false teeth/dentures, doyou have any problem: (y, n)66. Talking clearly? (y, n)67. Eating? (y, n)68. The way the false teeth/dentures fit? (y, n)69. Soreness? (y, n)70. How much do you like the way the falseteeth/dentures look?: (very much, quite a bit,OK, not much, not at all).Do you strongly agree, agree, disagree, orstrongly disagree, witheach of the followingstatements?71. Tooth decay can make people look bad72. Dental problems can be serious.73. Poor teeth will affect people’s work orother aspects of their everyday life.74. Dental disease is less important than otherhealth problems.75. I place great value on my dental health.76. It is

not

important to keep natural teeth.77. Having dental problems can cause otherhealth problems.


35

AIDS

78. Have you ever heard of AIDS: AcquiredImmunodeficiency Syndrome? (y, n, don’tknow, no answer).Tell me if you think that the following state-ment is true or false: (t, f).79. AIDS is a disease. (t, f).80. AIDS can cripple the body’s natural protec-tion against disease. (t, f).81. AIDS can be transmitted through bloodtransfusion. (t, f).82. AIDS can be passed from person to personthrough body fluids. (t, f).Do you “strongly agree”, “agree”, “disagree” orstrongly disagree” with each of the followingstatements?83. Dentists are a good source of informationabout AIDS.84. Dentists have a moral responsibility to treatAIDS patients.85. Patients with AIDS should be given thesame dental treatment as everyone else.86. I would

not

mind if my dentist treated AIDSpatients in his office.87. There are safety measures dentists can useto prevent the spread of AIDS.How much have you learned about AIDS fromeach of the following source: (a lot, some, a lit-tle, or none):88. Radio/TV: (a lot, some, a little, or none)89. Newspapers/magazines: (a lot, some, a lit-tle, or none)90. Your doctor: (a lot, some, a little, or none)91. Your dentist: (a lot, some, a little, or none)92. Your friends/colleagues: (a lot, some, a lit-tle, or none)93. Your church/religious leaders: (a lot, some,a little, or none)94. Your family: (a lot, some, a little, or none)95. National government agencies/authorities:(a lot, some, a little, or none)96. Public health campaigns organized by thelocal health authorities: (a lot, some, a little, ornone)97. Other (specify)

DENTAL CARE

98. Is there a dentist’s office or clinic that youusually go to for dental care? (y, n, don’t know,no answer)99. How long have you gone to that dentist’soffice or clinic for dental care? (seven answermodalities)100. If you need dental care, do you know adentist’s office or clinic you would go? (y, n,don’t know, no answer)101. What is the name of the office or clinicwhere you usually go/would go to?102. Do you see a particular dentist when yougo there? (y, n)103. What is the dentist’s name?104. What is the street address of the dentist’soffice or clinic?105. Which of the following best describes…(name of the person/office in Q. 101)(six answer modalities)106. How did you first find out about (Q. 101)(thirteen answer modalities)107. What is the main reason that you continueto use… (Q. 101) (fourteen answer modalities:e.g. Care is free, staff is courtous, waiting timeis short etc.)108. Do any of the following sources cover anyof your dental costs? (private insurance fromemployer, private insurance you pay yourself,government, dental clinic provides free care,other)109. Do you or your family pay anything forthe insurance/health plan? (y, n, don’t know,no answer)110. How often do you pay your dental insur-ance premium? (six modalities for frequency)111. How much do you pay for your dentalinsurance premium each time?Does your insurance cover all, part, or none ofthe costs of…112. Examinations and X-rays113. Cleaning teeth114. Filling teeth115. Oral ssurgery116. Othodontics

36

117. How long ago did you receive your lastdental care? 5six modalities)118. What was the main reason you did notvisit a dentist in the last two years? (cannotafford costs, don’t want to spend money ondental care, etc… seventeen modalities)119. At your most recent visit, did you go to thedentist’s offic or clinic you usually go for dentalcare? (y, n, no usual source of care)120. What was the reason you made your mostrecent visit to a dentist? (four modalities)At your most recent visit to the dentist, did youreceive… (y, n)121. An examination?122. Cleaning?123. Fillings?124. Crown/cap work?125. Root canal work?126. Denture work?127 Orthodontic work?At your most recent v isit to the dentist, did youreceive…128. Instruction in taking care of teeth andgums?129. X-Rays?130. Inlay work?131. Extraction?132. Bridge work?133. Periodontal/gum treatment?134. Fluoride treatment?135. Any other treatment?136. In the past twelve months, did you makeany other visits to the dentist’s besides this one?(y, n, don’t know, no answer)137.How many other visits did you make?138. Were the additional visits for care? (y, n,no usual source of care)During these additional visits, did youreceive… (y, n)139. An examination?140. Cleaning?141. Fillings?142. Crown/cap work?143. Root canal work?144. Denture work?145. Orthodontic work?

During these additional visits did youreceive…146. Instruction in taking care of teeth andgums?147. X-Rays?148. Inlay work?149. Extraction?150. Bridge work?151. Periodontal/gum treatment?152. Fluoride treatment?153. Any other treatment?154. Did or will dental insurance pay for thecost of the dental visits you made in the lasttwelvemonths? (y, n, no dental insurance)155. Apart from the cost payed by dental insur-ance, How much did you or will lyou paydirectly for all dental visits you made in the lasttwelve months?156. For your last visit to the dentist, did youhave to take time off work? (y, n)157. For your last visit, did you go directly tothe dentist from either home or work? (y, n)158. For your last dental visit, how did youtravel to the dentist’s office? (nine modalities)159. The last time you went, how long did ittake you to get to the dental office?160. At your last visit for dental care, how longdid you have to wait before you got to sit in thedentist’s chair?161. During your last visit to the dentist, howlong did your treatment take?162. For your last visit to the dentist, did you.(phone for an appointment, have a follow-upappointment… etc,)163. How many days were there between theday you made the appointment and the dayyou actually recived dental services?164. Did you have to pay anything directly(tnat is out-of-pocket costs) for this last visit?165. Could you have had the same work inanother place at a lower out-of-pocket costs toyou? (yes, definitely, yes probably, no, don’tknow)166. Why did you choose the extra cost of get-ting the care where you did? nine modalities


37

for examole: emergency, quality care, conve-nient location etc.)During your last dental visit, were you “verysatisfied”, “satisfied”, ”dissatisfied”, “very dis-satisfied” with:167. Getting an appointmant when youwanted it?168. The time it took to get there?169. The neighbourhood where the dentaloffice is located?170. The way you were made to feel welcomeby the receptionist?171. The way you were made to feel welcomeby the hygienist/dental chairside assistant?172. The way you were made to feel welcomeby the dentist?173. The information given to you about whatwas wrong with your teeth?174. The information given to you about whattreatment was provided to you?175. The quality of care provided?176. How up to date the dental equipmentseems?177. The amount of time you waited to see thedentist?178. The cleanliness and neatness of the office?179. The cost of your last dental visit (your out-of-pocket costs)?180. In the last two years, was there any dentalservice recommended to you by a dentist thatyou were not sure you needed?181. What was that dental service? (list of fif-teen modalities)182. Did you receive the dental service recom-mended?183. What was the main reason you did not getthe service recommended to you? (eleven pos-sible reasons)Now, I’d like to know how you feel about den-tists and dental care. Do you “strongly agree”,“agree”, “disagree” or “strongly disagree” witheach of the following statements?184. Dentists are able to relieve or cure most ofdental problems that patients have.185. I amafraid of dental visits because of pos-sible pain.

186. I will visit the dentist when I have dentalproblems no matter how busy I am.187. Dentists aree not always available when< i have dental problems.Now, I’d like to ask your opinion about dentistsin the public sector188. Public dentists explain a patient’s prob-lem to him or her.189. Public dentists always spend enough timewith the patients.190. Public dentists are very careful to checkeverything when examining patients.191. Public dentists prefer to fix up teeth rathertha n teach their patients to avoid problems.Now, I’d like to ask your opinion about dentistsin the private sector192. Private dentists explain a patient’s prob-lem to him or her.193. Private dentists always spend enough timewith the patients.194. Private dentists are very careful to checkeverything when examining patients.195. Private dentists prefer to fix up teeth rathertha n teach their patients to avoid problems.196. The cost of visiting a private dentist is tooexpensive for me.197. In the last twelve months, did you makeany visits to some place other than a dentist’soffice or clinic for advice on tratment of yourteeth and gums? (y, n)198. What type of person did you visit?199. How many visits did you make to this typeof provider in the past twelve months?200. What is the main reason you visited (typeof provider from Q. 198)? (Relief of pain, con-trol of bleeding, tooth extraction, other)201. What kind of treatment did you receive?(tooth extraction, medicine prescribe by doctoror nurse, traditional medicine, spiritual assis-tance or psychological counselling, traditionalhealing, other)During your last visit to this provider were you“very satisfied”, “satisfied”, “dissatisfied”, “verydissatisfied” with…202. The information given to you with whatwas wrong with your teeth and gums?

38

203. The information given to you about whattreatment was being provided for you?204. Your out-of-pocket costs?205. The quality of the dental care provided?206. The way you were made to feel welcomeby the provider?207. How much did you pay (out-of-pocket)for the treatment given to you?Finally, we need some background informationabout you and your family.208. Which of these best describes your cur-rent situation? (married, widowed, divorced,separated, never married, living with partner)209. How long have you been living at thisaddress?210. How long have you ben living in (DAU)?211. Which of these groups do you belong to(specify ethnic group)212. How many years of education did youcomplete?213. Which of the following describes bestyour current employment situation? (thirteenmodalities)

214. Did you ever work outside the home foras long as one year?215. What type of work do (did) you do?Please, briefly describe your job. (ten proposedshort description)216. Are (were) you self-employed or do (did)you work for someone else?217. Is (was) your main workplace your homeor somewhere else?218. Considering your present income (plusincome from others who live in the household)please give me the number of the category thatshows thehousehold’s total family income-before taxes and deduction- for the last twelvemonths (seven amounts in US $ ranging fromless than 5000 to between 50000 and 74 999).

Remark to the reader

: Skip patterns have notbeen indicated in this version of the adult ques-tionnaire. Similarly, indications provided to theinterviewer have been suppressed. The full ver-sion is published as an ANNEX to the ICSIIcomplete report published by WHO in 1997.

39

Basic indicators for development of quality of oral health systems in Europe – the approach of the World Health Organization

Poul Erik Petersen

1

This paper highlights the main experiencesgained from WHO European projects todevelop indicators for the quality of oralhealth systems and for the quality of oralhealth care, and suggests further initiativesin this direction as seen by WHO. Theseexperiences were culled within the frame-work of a European project entitled “ORA-TEL” (telematic system for quality assur-ance in oral health care).

The European Region is however, only oneof six WHO Regions which the global oralhealth programme serves. Therefore, whendealing with indicators for surveillance orfor quality of care, WHO as an interna-tional (United Nations) organization musttake into account the vast variations in sys-tems and conditions across the world, andadapt any wider approach to the definitionof health indicators to the given setting.

This figure shows what WHO considersimportant for information systems related to

oral health. Several European MemberStates have already established such systems

Figure 1. Oral health information systems

Oral health information systems

Risk factorssurveillance

Oral healthstatus

Care & intervention

Quality &outcome

Administrationof care

1. Group Leader, WHO Oral Health Programme, Geneva, Switzerland.

40

including outcome measures. Others havehealth information systems which focusonly on delivery of care and intervention.

The idea of the ORATEL project was toencourage the Member States of the Euro-pean region to harmonise their informa-tion systems. Many East-European coun-tries for example, traditionally record thenumber and type of services provided, thenumber of teeth extracted, the number ofdental fillings but not outcomes, i.e.whether intervention contributes to healthor not. Some western European countrieshave established more outcome-orientedinformation systems but neglect the pro-cesses. This WHO European projectsought to stimulate the development ofmore comprehensive data systems.Quality of care development and qualityof health systems development projectswere implemented by the WHO RegionalOffice for Europe to develop instrumentsin accordance with European Health forAll targets. Target number 31 - to improvethe quality of health care by use of appro-priate health care technology and the pro-vision of health information systems thatare based on the use of information tech-nology - was the most important policybasis of these projects.In the late 1990's it was observed that manyEuropean countries direly needed to improvecost effectiveness and the quality of theirhealth care. Patients were becoming increas-ingly aware of the treatment options availableand health professionals were increasinglyconcerned with ethical aspects and provisionof the highest possible level of care.

So when the WHO Regional Office forEurope embarked on the development ofindicators for quality purposes, it began by

mapping the indicators used in EuropeanMember States and the philosophiesbehind them. Many countries have estab-lished schemes to monitor what dentists orproviders of dentistry are doing by “lookingover their shoulders”, while few have estab-lished self-evaluation systems. The conceptof the projects developed in the EuropeanRegional Office was to apply more modernapproaches to quality development basedon sharing the experience of others andmore particularly to integrate these withstate-of-the-art information technology.

The idea was to focus on how, by learningfrom each other, we can move the out-come curve from right to left, towards con-tinuously improved outcomes. The abovediagram illustrates this. At a practicallevel, WHO then developed a number ofindicators that related to clinical perfor-mance and public health dimensions ofproviding care for populations. Indicatorsneeded to be developed that addressedpractice management and the inter-rela-tionships between patients and providers,incorporating new quality aspects: whatdo the patients tell us, are they satisfiedwith their treatment and care, and howcould community preventive programmesimpact the population in terms of knowl-edge, attitudes and self-care.Obviously, the projects had to match theneeds of the national oral health system,allowing easy day-to-day management andadministration of oral health services. Wealso sought to achieve consensus on basicminimum datasets or sets of quality indica-tors. By reducing the number of indicatorsto a minimum, it would be easier to inte-grate these indicators into a software infor-mation system that could be used by pro-viders of care across national boundaries.

Basic indicators for development of quality of oral health systems in Europe

41

ORATEL had three phases. First we devel-oped a number of indicators and analysedthe IT systems then available on the marketwhich were suitable for developing the so-called “quality of care” tools we wanted todesign; then, in phase two, we developedthese tools; finally, in phase three, a numberof countries participated in validating the rel-evance of the quality indicators developedand the information system itself, to allow anassessment of the practicality of the informa-tion gathered. Various reports - available tothe current SANCO project - document anumber of intercountry comparisons andactivities in support of quality of oral healthcare in Europe (WHO 1992, Petersen 1994).

The most significant milestone in the pro-cess was a list of indicators developed at aconsensus meeting hosted by WHO in

Copenhagen in 1992. The main objectiveof this meeting was to come up with indica-tors for proactive decision support and forretrospective evaluation or quality assur-ance which, in line with a new approach toquality measurement, comprised structure,process and outcome. Especially relevantto the SANCO project are the populationrelated indicators developed for use at clin-ical level and various administrative levels,i.e. sub-national, national and suprana-tional. In addition, an interactive teachwareprogram was developed. A number of pro-viders of care and health care administra-tors in the WHO European Member Stateswere invited to work with the data pro-duced at local, regional, national andsupranational level in order to assess whatindicators were practical for developmentof quality of oral health systems.

The system was based on informationextracted from a specially designed patientrecord which gives comprehensive informa-tion about the status and treatment providedto the patients as well as various follow-upmechanisms established at the clinical pro-vider level. The list of indicators comprisedfive components: oral status, intervention ortreatment procedures/processes, follow-upmechanisms, patient satisfaction and patient

administration. A total of 31 indicators fororal status were agreed upon, the philoso-phy being that oral status indicators wouldhave to measure outcomes (Appendix 1).Other indicators related to process andstructure or the organisational setting ofcare: indicators on intervention; indicatorson recall and follow-up; indicators onpatient satisfaction; and indicators related toadministration and organisation.

Figure 2. Indicators developed for use at clinical level and various administrative levels

Indicatorsand standards

Supranational

levelNational

level

Sub-national level

Clinical/individual dental practice level

42

The software tool was then designed to com-pile information selectively, e.g. by year, ageor region. A number of indicators from thisdatabase could be extracted for a Europeandatabase. Below is an example (distributionof people by caries, whether they are caries-free or not) of the many indicators extractedand which were available to the individualprovider, to health care administrators orauthorities at supranational level.After specifying these indicators, theWHO Regional Office for Europe devel-oped other systems to serve the needs ofeastern European countries, whose healthsystems at that time lacked software andparticularly computers. “Paper-based”

data submission systems were designedfor the so-called Oral Status EURO project(WHO 1996). Indicators were developedfor access and equity, acceptability anduser choice in health systems, and for bestoutcomes.The establishment of surveillance systemsis recommended in the World HealthReport 2002. Two information systemshave already been established in oralhealth that relate to the Global Databankof the 1960's and yet another informationsystem, CAPP, is available on the internet.The basic indicators, which are detailed inthese databases, relate primarily to themost prevalent of oral diseases and condi-

Figure 3. WHO indicators for quality of health care development

Figure 4. Oral health quality indicators in the ORATEL system

Structure Process Outcome

Organizational Health care Effect of care

setting of care intervention and patient

satisfaction

WHO: Indicators for quality of health care development

Oral Health Quality Indicators in the ORATEL system

Population-related indicators

* Oral status

* Treatment procedures/Intervention

* Follow-up/Recall visits

* Patient satisfaction

* Patient administration

A1-A31

B1-B27

C1-C6

D1-D8

E1-E15


43

tions (i.e. dental caries, dentate status,periodontal disease, edentulousness), andin the future the list of indicators should beexpanded to include other dimensions oforal health. The manual “Oral health sur-veys, basic methods” was first developedin 1973 to describe the dental disease pro-file in many countries or many regions andto assess trends over time, and needsupdating as well.For all developed or developing countriesepidemiological indicators can help usanalyse disease trends and identify whereintervention is needed. Standard agegroups were specified for surveillance atintercountry and country levels, but usersof the basic methods manual are encour-aged to investigate other age groups rele-vant to community oral health care. Thereare very few data on the elderly, a popu-lation segment that requires special con-sideration particularly in a European con-text.As one basic indicator it is recommendedto record the number of teeth present. It isan open question whether a physical mea-

surement is really necessary, or whetherwe can rely on valid questionnaire data.With such information it may be morecost-efficient to answer questions posedby public health care administrators orpolicy makers: Do we strive for better oralhealth or do we tackle inequity issues? Arecent survey in Denmark shows thatinequity in health is still prevalent in termsof dentate status.In the European context, the time hascome to consider additional informationas part of efforts to improve physical mea-surements. Risk assessment is one of these,and a model of risk factors in oral health isalready detailed by the WHO ORH Pro-gramme in the World Oral Health Report2003 (Petersen 2003). The WHO OralHealth Programme is currently assessingrisk factors and linking these with existingdata from individual Member States. Itwould also be of interest to discuss indica-tors related to impairment of function, oralillness, quality of life and relationshipsbetween oral and general health.

Figure 5. ORATEL software: example of indicators extracted

44

In conclusion, ORATEL is more than justanother health information system. ORATELis a “bottom-up” process, starting at the den-tal unit and ultimately serving as a tool for aninternational network for quality develop-ment in oral health care. It will both supportmanagement and administration of dentalclinics and be an integrated part of a qualityassurance system to promote a standardquality level for oral health care. It’sadvanced educational and decision supporttools can be used at all professional levels.Once ORATEL is operational, the resultsfrom its widespread use should result in: (a)lower incidences of oral diseases; (b) higherstandards of public and private oral healthcare delivery; (c) cost effectiveness of pub-lic and private oral health care delivery; (d)equity in oral health care delivery; and (e)self-awareness and improvement of qualityin oral health care by the providers.WHO is in the process of providing a datacollection tool for countries whichincludes not only oral but also generalhealth indicators in public health pro-grammes. These efforts will strengthen sur-veillance instruments in the control of

noncommunicable diseases and healthpromotion. The outcomes of this work willbe available to the European project in thenear future.

References

Petersen PE, Staehr Johansen K. ORATEL:Telematic system for quality assurance in oralhealth care (AIM Project 2029).

Computer Meth-ods and Programs in Biomedicine

1994; 45:141-3.

Petersen PE. The World Oral Health Report2003: Continuous improvement of oral health inthe 21

st

century – the approach of the WHO Glo-bal Oral Health Programme.

Community DentOral Epidemiol

2003; 31: 3-24.Petersen PE, Kjoller M, Christensen LB, Krus-

trup U. Changing dentate status of adults, use ofdental services, and achievement of national den-tal goals in denmark by the year 2000.

J PublicHealth Dent

(In press 2003).World Health Organization. Manual on indica-

tors for quality of oral health care. Copenhagen:WHO Regional Office for Europe, 1992.

World Health Organization. Oral Status EURO.Copenhagen: WHO Regional Office for Europe,1996.

Figure 6. Basic indicator: number of teeth present

0

20

40

60

80

1987 1994 20001987 1994 20001987 1994 2000

%

Changing oral health of65-74-year-olds, Denmark

Petersenet al, 2003

20 teeth or more

EdentulousRegular dentalattendance


45

A

PPENDIX

1

List of quality of oral health care indicators for use at clinical (a), national/regional (b) and supranational (c) administrative levels

A. Oral status a b c

1. Edentulous persons X X X

2. Teeth present per person X X X

3. Persons with 20 teeth or more X X X

4. Caries free persons X X X

5. DMFT/dmft per person X X X

6. DMFS/dmfs per person X X

7. Separate components (D, M, F, d, m, f) X X X

8. Tooth surfaces affected (mesial, distal etc.) X

9. Teeth with untreated caries X

10. Percentage of surfaces with secondary caries (recurrent caries) X

11. Tooth surfaces with root caries X

12. Restorations with marginal defects X

13. Root fillings present X X

14. Insufficient root fillings X

15. Teeth with pulpal diagnosis X

16. Teeth with visible plaque X

17. Tooth surfaces/sites with visible plaque X

18. Sextants with gingival bleeding X X X

19. Sextants with calculus (supra and/or sub) X X X

20. Sextants with shallow pockets (4-5 mm) X X X

21. Sextants with deep pockets (6 mm or more) X X X

22. Teeth with loss of attachment (more than 1/3 of root) X X

23. Persons with functional dentition (natural and/or artificial) X X X

24. Type of extracted teeth X

25. Teeth with occlusal interference X

26. Persons with full dentures in upper and lower jaw X X X

27. Teeth with fractures (enamel, dentine, pulpal involvement) X X

28. Teeth with tooth wear into dentine (abrasion, attrition) per person X

29. Persons with symptoms from TM-joints and/or muscles (subjective/objective) X X

30. Persons with malocclusions treated or referred X X

31. Persons with oral mucosal lesions X X

46

B. Treatment-procedures/interventions a b c

1. Persons having received professional plaque removal X X

2. Persons having received fluoride application (topical) X X

3. Teeth having received fissure sealing X X

4. Teeth having received restorations

a.One surface restoration X X X

b.Two/more surface restorations X X X

5. Type and brand materials used X

6. Teeth with pulp treatment X

7. Teeth with clinical complications during treatment (perforation, instrument-related overfilling, periapical lesions)

X

8. Crown restorations X X

9. Persons having received crown restorations X X

10. Bridge restorations X X

11. Persons having received bridge restorations X X

12. Persons having removable partial dentures X X

13. Persons having received full dentures X X X

14. Persons treated by implants X X

15. Teeth extracted X X X

16. Persons having received scaling for periodontal treatment X X

17. Persons having received surgical periodontal treatment X X

18. Persons treated by oral surgical intervention (other than B17) X

19. Persons having received medication for therapeutical reasons X

20. Persons treated for benign oral mucosal lesions (denture stomatitis, candidiasis, aphtae, chelitis)

X

21. Persons with biopsy X

22. Persons with correction of occlusal disharmonies/interferences (by grinding only) X

23. Persons treated for orthodontic reasons X X

24. Persons treated by removable orthodontic appliances X

25. Persons treated by fixed orthodontic appliances X

26. Persons referred to specialist for premalignant and malignant conditions X X

27. Minutes per person spent on individual or group-based oral health instruction/education X X


47

C. Recall visits/follow-up a b c

1. Persons recalled for control of level of oral hygiene X

2. Persons recalled for control of periodontal conditions X

3. Teeth with replacement of restorations X X

4. Persons recalled for control of oral mucosal lesions X

5. Persons recalled for control of occlusal and functional status X

6. Persons with denture replacements X X

D. Patient satisfaction a b c

1.

a

Persons who felt oral health services accessible X X X

2.

a

Persons who experiences no excess waiting time in the dental office X

3.

a

Persons satisfied with services rendered X X X

4.

a

Persons who felt informed about treatment alternatives X

5.

a

Persons satisfied with physical facilities in dental office X

6.

a

Persons who felt that the dentist had sufficient time for discussion X

7.

a

Patients who felt cost of treatment acceptable X

8.

a

Persons complaining of treatments performed per year X X X

a. Special recording needed.

E. Patient administration a b c

1. Persons with relevant social/medical history (diseases, medication, background data) X

2. Persons classified by risk group (caries, periodontal diseases, based on clinical-biological tests)

X

3. Persons classified by social/behavioural risk factors X

4. Total number of patients per dentist per year X X X

5. Number of patients in regular care (at least once a year) per dentist per year X X X

6. Number of patients in emergency per dentist per year X

7.

a

Number of patients in public care programme free of charge per dentist X

8.

a

Number of patients in public/national health insurance scheme per dentist X

9.

a

Number of patients in private health insurance scheme per dentist X

10.

a

Number of patients in mixed health insurance schemes per dentist X

11.

a

Number of working hours per dentist per year X X X

12.

a

Number of working hours per dental hygienist per year X X X

13.

a

Number of working hours per chairside assistant per year X X X

14. Total number of patient attendances per year X X

15. Total number of new patients per year per dentist X X

a. Special recording needed.

48


Helen Whelton

1

Introduction

Over the last 30 years interest in the rela-tionship between the system of deliveringhealth care and the health of those eligiblefor care under the different systems hasincreased. The late Archie Cochrane wasthe first to articulate the idea that the effec-tiveness and efficiency of a health care sys-tem was an important area of study and thatmuch effort and resources could be wastedif a system and the procedures within a sys-tem were not subject to regular and rigor-ous study and evaluation (Cochrane 1972).He highlighted the fact that measuringactivity alone without measuring the effectof that activity on the health of the popula-tion was seriously inadequate.

The concepts of cost effectiveness andcost benefit began to be frequentlyaddressed in the international health ser-vices literature. The Archie Cochrane Cen-tres for evidence based health care havebeen established in the US and UK tohonour this great innovator in the field of

Health Services Research. In 1972, theWorld Health Organization in collabora-tion with the United States Public HealthServices initiated a major InternationalCollaborative Study (ICS) on Oral HealthCare Systems (WHO 1995). This study,involving ten countries with widely vary-ing oral health care delivery systems,attempted to ascertain whether there wasa link between the characteristics of thesedifferent delivery systems and the oralhealth levels of those eligible for carewithin the different systems. The report ofthis study generated considerable interestand debate amongst researchers and thoseresponsible for developing policies fororal health care delivery systems. A livelydebate followed publication of the results,particularly those from the cities of Yama-nashi in Japan and Cantebury in NewZealand. One outcome measure investi-gated in this ICS project was the level ofedentulousess amongst representative sam-ples of those aged 35-45 years of age. InYamanashi this percentage was 0%,whereas in Cantebury it was 39%. A

1. Oral Health Services Research Centre, University Dental School and Hospital, Cork, Ireland.


49

detailed analysis of the structures and pro-cesses of the oral health care delivery sys-tems in these cities revealed major differ-ences not only in the systems themselvesbut also in the attitudes to tooth loss. It wasconcluded that cultural factors were asimportant as the characteristics of thedelivery system (e.g. payment methods) indetermining oral health care outcomes.A number of reports in the late 70s high-lighted the wide variation in the structureand processes of the different oral healthcare systems worldwide (Ingle and Blair1978, Kostlan 1979). In the early 80s majordiscussions were initiated in the UnitedKingdom regarding the NHS system ofdelivering dental care (Dental StrategyReview Group Report 1981) leading tofundamental change in the system in 1984(Downer et al. 1994). These discussionshighlighted the fact that whilst changingsystems was both regular and widespread,the basis on which these changes weremade often lacked an evidence base.

Health policy in the member states isrequired to address difficulties in thefinancing and delivery of health care. Sys-tems design is required to pay particularattention to addressing pressures for rapidincrease in expenditure, perceived defi-ciencies in coverage and access to ser-vices, and concerns about the efficiency ofdelivery. Systems design is also required topay increasing attention to convergence ofhealth care coverage and financing withinthe EU in order not to jeopardise the rightof free mobility of persons and servicesbetween the Member States. Positively,the health care systems of all EU MemberStates should finally offer equal opportuni-ties with respect to maintenance of healthand treatment of illness for every EU Citi-

zen in each EU Member State. The policyproblems to be solved for these purposesare heavily influenced by demographicand technological factors. These requirethat available policy instruments beemployed to maximum effect in the inter-est of improved system performance.Policy discretion applies principally to theareas of financing, payment and regula-tion. Considerable effort has thereforebeen employed by the Member States,within their distinctive national traditions,to improve health care financing anddelivery systems. Policy reform hasfocused on changes in the funding mech-anisms and the payment or recoupmentarrangements. More recently, reform strat-egies have extended to a restructuring ofthe organisation of health care systems tostrengthen control and review procedureswhile stimulating the search for greaterproductivity.Within the reform strategies, particularemphasis has been placed on the design ofsystems for provider payment which rein-force the search for efficiency whileachieving cost containment objectives.The effectiveness of alternative strategiesin terms of cost containment is reasonablyclearly established and has been the sub-ject of an extensive literature. The impactof payment systems on the quality of careas well as on the effective utilisation of ser-vices is much more problematic. The mea-surement of final outcome as the ultimatetest of quality is even more difficult bothfor the health system as a whole and forindividual services.

Many fundamental differences existbetween the health care delivery system ofeach EU Member State. It is reasonable toask if these differences explain some of the

50

varying levels of health throughoutEurope. If it does then it would be sensibleto include those factors which promotehealth and exclude those which are detri-mental to health in any policy changesbeing introduced on a Europe wide basis,for example as part of convergence ofhealth care systems.

Oral health care systems share many ofthe structural challenges faced by healthcare in general. They have also been sub-ject to review and redesign in terms offunding and payment policies. Outcomeindicators are more accessible, howeverin the context of oral health care than inhealth care generally because of the exist-ence of well-established measures of oralhealth status. These measures representpotential indicators of the impact of thedesign of an oral health care system on thecontent and outcome of interventions.They therefore represent an important toolfor proceeding beyond process and costevaluation to the level of the effectivenessof system design. In this sense, oral healthcare represents a marker for policy devel-opment with regard to health care systemsas a whole. The fact that in each EU Mem-ber there are clearly established oralhealth care delivery system and the factthat there are now clearly defined mea-sures of oral status makes oral health anideal example in which to develop meth-odologies aimed at linking characteristicsof a health care system with the health ofthose eligible for care under that system.

It was against the above background thatthe Oral Health Services Research Centre,University Dental School and Hospital,Cork, applied for funding in collaborationwith six partners in the EU to conduct aproject with the following aims:• To develop a methodology designed to

establish links between characteristics ofa health care system and health outcome

• To determine the characteristics of oralhealth care systems which promote oralhealth and those which are detrimentalto oral health

Essentially the project planned to harnessinformation from the natural experimentcreated by seven different methods of deliv-ering services in Europe, taking account ofthe background diversity in levels of oralhealth in the seven different regions.

Methods

The Partners in this project were oral healthservices research groups from: Denmark,England and Wales, France, Ireland, Neth-erlands, Spain, Germany. Romania joinedthe consortium after the first year of theproject and participated in some of the dis-cussions and activities

1

. Following a seriesof meetings of the consortium a detailedprotocol, designed to achieve the aims andobjectives of the project, were agreed. Ini-tially a situation analysis of the seven par-ticipating countries was undertaken. Thissituation analysis included demographicvariables such as population figures, per-cent of GNP spent on health services and

1.

Members of the consortium: Ireland

Project Leader

D. O’Mullane, H. Whelton, A. Murphy, K.Neville, S. O’Hickey, M. Wiley, D. McCarthy, P. Flynn.

Denmark

P.E. Petersen, M. Vigild, L.B. Chris-tensen

England and Wales

M. Downer, J. Todd (RIP), D. Parkin, J. Clarkson, M. Deverill

France

P.M.Cahen, A.M. Obry-Musset, V. Fabien

Germany

A. Borutta, W. Kunzel

The Netherlands

K. Konig, G.J.Truin, E. Bronkhorst

Romania

A. Illiescu

Spain

C. Manau, E. Cuenca, J. Echeverria, R. Artal.


51

on oral health services, number of regis-tered dentists and the dentist populationratios. Data on oral health was also obtained,such as caries levels amongst 5 and 12 year-olds and the number of natural teeth presentand levels of edentulousness amongst 35-44year-olds and 65+ year-olds. These datawere collected for 1980 and 1990. Theresults indicated considerable changes overtime and wide variation in most of theparameters investigated. For example thedentist to population ratio varied from 1,353in Denmark to 3,353 in Spain. Edentulousrates also varied widely, for example from31% in Spain to 78% in the Netherlandsamongst 65+ year-olds. During this initialphase also the demographic data and thedata on oral health which was part of themanagement and administration of the dif-ferent oral health care systems was assessed.It was found that there was considerable vari-ation in the kind of data collected in the dif-ferent systems and the method of collectionwas such it could not be adapted to suit thepurposes of the project.

At this early stage of the project also, DrDavid Parkin the Health Economist on theteam led a subgroup of the consortiumwhose task was to develop a theoreticalmodel which would dictate the informa-tion to be collected in order to achieve theaims of the project. This model is pre-sented in figure 1. The model separates theproduction of Oral Health Care from theProduction of Oral Health. In the upperpart of the diagram the level of Profes-sional Oral Health Care is subject to fac-tors which relate to dental practice such asthe chair-side time spent by the dentistsand auxiliary dental workers, the type ofpremises, the equipment and the suppliesused, as well as the characteristics of the

health care systems and the cultural orsocial environment in which oral healthcare was delivered. In the lower half of thediagram, there are other factors influenc-ing oral health, such as self care, as well asthe environment in which the health caresystem operates and the cultural andsocial environment in which the individ-ual lives. Having developed this model thegroup then set about designing a numberof data collection instruments for themany variables likely to impact on theagreed model. The two halves of themodel were treated separately eventhough there is an assumption that anyfactors which increase the Production ofOral Health Care will have a positiveimpact on Oral Health itself. In otherwords, the more efficient the system is indelivering oral health care, the better theoral health of those eligible for care in thatsystem. Data was collected from adminis-trators of the different systems, from den-tists practising within the systems (inter-view and questionnaire) and from patientswho were being treated under the system(clinical examination and questionnaire).The data collection instruments were

Figure 1. Model for the production of oral carefunction and for the production of oral healthfunction

Production of Oral Care and of Oral

SystemdesignPrevalenceTimeSupportEquipmentMaterials

Professional Care

Self Care

Environment

System

Production of Health Function

Production of Care Function

ProfessionalOral HealthCare

Oral Health

52

piloted extensively taking account of thefact that the parent language of the partic-ipants varied. The questionnaire designteam was lead by the Dutch group whohad considerable experience in designingquestionnaires for both dentists andpatients (Eijkman et al. 1984, Hoogstraten& Broers 1987). The data collection instru-ments are attached, appendix 1.

Results

The results of the project are contained inthe Report to the EU Commission (1997).Further details of the project includingresults have also been recently published(Parkin & Devlin 2002). Conveniencesamples of dentists and of patients wererecruited in the different countries. In total316 dentists participated in the projectand 1,501 patients were clinically exam-ined. In the case of the first part of themodel, namely Production of Oral HealthCare one dependant variable or outcomemeasure is selected for illustrative pur-poses namely average number of patientsseen per hour worked in system by eachdentist. The independent variablesincluded in the stepwise regression analy-sis used to test the model are : average ageof dentists in system, age of dental unit,average number of hours per weekworked by dentists chair side, averagenumbers of hours per week worked bydentists, administration, number of chairsconcurrently operated by dentist, timeworked by reception staff, time worked bychair side assistants, time worked byhygienists, time worked by staff conduct-ing health education, time worked on‘other tasks’, average number of weeksworked per year by each dentist in sam-ple, number of years spent practicing

since qualifying by each dentist, numberof population per dentist in system, den-ture fee as multiple of filling fee, whetherpatient contributed payment to treatmentor not, country of origin.

In the case of the second part of the model,namely the Production of Oral Health twodependant variables were considerednamely the state of the oral health as per-ceived by the patients themselves and thenumber of sound unrestored teeth: Age,attendance pattern, tooth brushing fre-quency, whether they had a check-up inthe last 2 years or not, had subjects con-sulted a non-dentist, educational level,employment status, satisfaction with ser-vice, gender, percentage of fees borne bypatients, denture fee as a multiple of fillingfee, sugar consumption in country (kg/perperson per year), country of origin wereincluded as independent variables.

In this study, the independent variablesfound to impact on the number of patientsseen per hour (production of oral healthcare) were average age of dentists (positive,the older the dentist the more patients seenper hour by the dentist), dentist chair sidehours (negative), dentist administrationhours (negative), denture fee as a multipleof filling fee (negative), dentist populationratio (negative), whether patient contrib-utes to treatment. The adjusted R-squaredfor this analysis was 0.49. The country oforigin variable was not significant.In the case of the production of oral healthmodel, two outcome measures wereincluded in the regression analysis in orderto illustrate the potential of the modeldeveloped in this project. Namely the oralhealth status of the patient as assessed bythe patient and the mean number of sound


53

untreated natural teeth as assessed by thedentist during the clinical examination. Inthe case of the latter, the factors having asignificant impact on the factor were age(negative, the older the patient the less nat-ural sound teeth present), attendance fre-quency (negative), consultancy in non-dentist for advice (negative), educationallevel (positive), gender (positive, femaleshad more), percentage of fees paid bypatient (positive), denture fee as a multipleof filling fee (positive). Country of originwas a significant factor in three samples,Germany (negative), France (negative),Spain (positive). The adjusted R-square forthese significant factors was 0.34.

Discussion

One of the main objectives of this projectwas to establish a methodology for assess-ing the link between the characteristics ofa health care system such as eligibility,methods and levels of payment and thehealth status of those eligible for careunder the system. It was realised from theoutset that any linkage between a healthcare system and the health of those caredfor under the system would be complexand difficult to measure. Using oral healthas a model, however, it was felt thatbecause of the recent advances in definingoral health outcomes there was a greaterlikelihood of developing methods forassessing the links between structures andinputs of oral health care systems and out-comes, than for other health care systemsin which outcome measures are less easilydefined. Again it is important to emphasisethat the comments made on the resultsobtained are purely illustrative of the kindof interpretations that could be producedif fully representative samples of dentists

and patients in the different systems wereselected to participate in the project.

It was interesting that even though exten-sive data was routinely collected as part ofthe administration and management ofeach of the systems studied, these datawere collected in many different formatsand for many different reasons and there-fore were not comparable between coun-tries at any level and could not be used toachieve the aims of the project. The OralHealth Services Research Centre in Cork iscurrently engaged in a number of projects,the overall aim of which is to develop cri-teria for increasing the usefulness of rou-tine data in measuring the efficiency oforal health care delivery systems.

The consortium devoted considerable timein arriving at a consensus on which clinicaloutcome measures were most suitable forcomparing the efficiency of oral health caredelivery systems. Whilst there was agree-ment that the number of natural teethpresent was a measure which took intoaccount not only the oral health status of theeligible population but also to some degreethe extent to which treatment was impact-ing on oral health, the need to further con-sider this matter needs to be emphasised.The current project being undertaken byProfessor Bourgeois and his team will hope-fully achieve a consensus on this issue.

A method for establishing the possible linkbetween the health characteristics of a caresystem and the health of those eligible for careunder that system is the primary aim of thisproject. In order to simplify the conceptualisa-tion of the possible link it was decided to con-sider separately the production of oral healthcare (sometimes referred to as “productivity”)

54

and the production of health. In a health caresystem providers are deployed to carry outtasks such as fillings, crowns, etc, the underly-ing assumption being that the carrying out ofthese tasks will result in better oral health. Putin another way it is assumed that the morework a dental provider such as a dentist orhygienist carries out, for a given remunerationthe more efficient that system is. The results ofthe modelling exercise developed in thisproject clearly show that the approach hasconsiderable merit; from a conceptual pointof view results show that considering produc-tion of oral health care and production of oralhealth separately is a useful approach andneeds to be developed further.

It should be emphasised however thatconsidering the models separately is onestage towards a more comprehensive viewand does not in itself constitute theapproach advocated. A further stage ofmodelling is required, in which the twomodels are jointly estimated, makingexplicit the links between them andenabling a proper view of the importantrelationships between them, of the impor-tant relationships between oral health careproduction, oral health production andfactors which influence them. As stated,this additional complexity was not possi-ble within this pilot project, but remainsan essential feature of future work.The decision to select the mean number ofpatients seen per hour by the dentist as themeasure of production of oral health careor ‘productivity’ was an arbitrary one. Nodoubt other equally appropriate measuresfor the production of oral health care, e.g.the number of fillings relative to the num-ber of extractions carried out per week, thenumber of specific items of treatment con-ducted per hour or week could be assessed.

However, the time available to the consor-tium for this project considerations of all ofthe various possible measures of ‘produc-tivity’ was not possible. Nevertheless, byusing the mean number of patients seen perweek as a reasonable measure of ‘produc-tivity’ the results illustrate the usefulness ofthe methods adopted.

It is interesting that the consortium in theirproposal for this project to the Commissionhypothesised that one characteristic whichmight have an effect on the production oforal care and as a result, possibly also onoral health was the system of payments todentists for work undertaken. The resultsshow that two of the independent variablesconcerned with payment which were cho-sen, namely the ratio of denture fee to sin-gle surface filling fee and whether or notthe patient made a contribution towardspayment of treatment, both had significantlinks with the number of patients seen perhour. In the case of the former it was foundthat the greater the fee obtained for fullupper and lower dentures relative to thefee for a single surface filling the lesspatients seen per hour by the dentist. Froma clinical point of view there is some sensein this relationship in that the higher fee fordentures might encourage more emphasison work on dentures; perhaps the fitting ofdentures might take longer to completehence the reduced number of patients perhour. Whilst it is tempting to attempt toexplain in this fashion the clinical sense ofthe relationships found between thedependent variable chosen (mean numberof patients seen per hour), and the variousdependent variables, the methodologicalnature of the project must again be empha-sised. Further detailed work is required toconsider further appropriate and relevant


55

independent and dependant variables forthe production of oral health care model.The results presented show that themethod chosen has considerable meritand future possibilities.It was decided to derive two measures of oralhealth, one based on the patients opinion oftheir oral health status and the other basedupon the clinical examination conducted bythe dentist. The measure of oral health cho-sen from these two sources is again arbitrary,the choice being simply made to illustratethe method used. Future work in this areawill need to focus on, for example, whatcombination of patient-based and clinician-based measures could be used to give a sim-ple measure of oral health. One approach tothis is to consider explicitly the weights to beattached to different aspects of oral health,using some variant of the utility indexapproach. This could be applied both topatients and to dentists.As in the case of the production of oralhealth care model, the model of productionof oral health outlined in this report hasconsiderable potential and should be fur-ther developed. A particularly fruitful areafor further work should be the developmentof the linkage between factors found to besignificant in the production of oral healthcare with the level of oral health.

In summary a method for measuring thelink between system of delivering anaspect of health, namely oral health, withthe oral health of those eligible for careunder that system has been developed.The background to the development of theproposed model is outlined. The complex-ity of the links between an oral health caresystem and the oral health of those eligiblefor care under the system required thatseparate models for the production of oral

health care and the production of healthbe developed. For both of these models anumber of factors have both positive andnegative influences. Further work isrequired on the data collection to deviseappropriate combinations of independentand dependent variables for use in themodel of production of health care andproduction of health. Furthermore, therelationship between factors affecting pro-duction of care and production healthneeds to be considered so that a furthermodel can be developed to quantify therelationship between both.

References

Cochrane AL (1972). Effectiveness and effi-ciency; random reflections on health services.The Nuffield Provincial Hospitals Trust, 1-3.

Dental Strategy Review Group Report (1981);towards better dental health – guidelines for the future.London: Department of Health and Social Security.

Downer MC, Gelbier S, Gibbons DE. (Assisted byGallagher, J.E.) (1994). Introduction to Dental PublicHealth, F.D.I. World Dental Press Ltd, London.

European Union, Research and TechnologicalDevelopment Programme. Efficiency in Oral HealthCare. The Evaluation of Oral Health Systems inEurope. Biomed 1, Final Report, January 1997.

Hoogstraten J, Broers NJ. The Dental AttitudesQuestionnaire: comparing two response formats.

Community Dent Oral Epidemiol

1987; 15: 10-3.Ingle JI, Blair P (1978). International Dental Care

Delivery Systems. Issues in Dental Health Policies.W.K. Kellogg Foundation, Battle Creek, Michigan.

Kostlan J. (1979). Oral health services inEurope. World Health Organization, RegionalOffice for Europe, Copenhagen.

Parkin D, Devlin N. Measuring efficiency indental care. In Scott, A, Maynard, A and Elliot, R.(Editors) Advances in Health Economics, JohnWiley and Sons, Chichester, 2002.

World Health Organization (1985). Oral HealthSystems: An International Collaborative Study,Quintessence, London.

56

A

PPENDIX

1

Questionnaire Patients (1)


57

Questionnaire Patients (2)

58

Clinical Examination


59

Questionnaire to Dentists

60


Manuel Bravo

1

, Juan Carlos Llodra

1

and Frederico Simón

2

The International Programme conductedin 1989 by a Joint Working Group FDI/WHO was to list the factors influencing thebalance between care needs and dentalworkforce needs for optimal oral health(WHO 1989). The objective of the JWG6was to provide guidelines for planning andmonitoring for oral health with a standard-ised working tool to analyse the situationand develop short, medium and long termplanning for the necessary number of den-tists sufficient to meet the required needs

(Table 1)

. The philosophy of the Man-power Programme was that (i): many fac-tors and/or indicators need to be taken intoconsideration to standardise the approachof professional demography; (ii) the opti-mal number of oral health professionalswas not be rigid but will be evolutive inrelation to variations of epidemiological,demographic, social and economical fac-tors; (iii) the necessity to consider in man-power the essential notion of the develop-ment of oral conditions, the effect of healtheducation and prevention strategies.

Manpower necessity

Historical data for the Dental Workforcein EU countries show an increase in thenumber of dentists compared to popula-tion, particularly for Spain and Portugal.The

Figure 1

is derived from OECD databases (OECD 1996, 1998, 2000), andshows, from 1960 to 1998, the popula-tion/dentist ratio in 14 EU countries (Spainand 13 unidentified lines, with Italyexcluded because dentists were includedin the medical census up to recently). Oneshould highlighted Spain and Portugal,where up to early 80s, the population/den-tist ratio was higher than in the rest, butknowdays those countries are within theEU mean.For example, the thick line representingSpain can be divided into two portions:from 1960 when the population/dentistratio was 10,970 (30.6 mill. pop./2,788dentists), to 1980 (ratio = 9,506; 37.5 mill.pop./3,946 dentists). This means anapproximate constant ratio two to five

1. School of Dentistry, University of Granada, Spain.2. Chief Dental Officer, Spain.


61

times greater than other EU countries (withthe exception of Portugal, represented bythe line above Spain). In striking contrast,the period from 1980 to 1998 (when theratio was 2,440; 39.4 mill. pop/16,133dentists), shows a limited increase in pop-ulation (4.9%) accompanied by a hugeincrease in dentists (308%) and a largereduction in the ratio (74.3%) comparedto the other EU countries.

There are, of course, two sides to this“growing” problem: the supply side(involving workforce analysis of the num-ber of dentists, trends, etc.) and the utilisa-tion side, which is determinant in measur-ing its magnitude.As the market for dental services is mod-elled as a combination of supply anddemand (Furino & Douglass 1990), anyrapid increase in the number of dentistsshould bring about efforts in nationwide

Table 1. Planning flow chart (WHO, 1989)

To

Social/political policies for health • Care organization and approaches • Funding parameters and policiesCare facilities • Care profiles and procedures • Personnel types and skills • Training facilities and outputPopulation parameters • Urban/rural distribution and trends • Ecology-based factors affecting demand

Proposed goals

Population estimates forplanning period by age cohortDemand for services estimates

Average time needed perperson per year forpreventive and treatmentservices at the start and endof planning period for each4 cohorts(i)(ii)(iii)(iv)

Average time which canactually be delivered perperson per year for preventiveand treatment servicesat each end of planning period,

Agreed goalsTypes of services and organizationPersonnel types, skills and numbersAppropriate personnel production policies

Maximise oralhealth andachieve agreedgoals

Data needed for calculations Calculations Data needed for modifying factors

Oral health status• Disease levels, profilesand trends• Preventive servicesand treatment needsestimates

0-14 years15-29 years30-64 years65-79 years

Decisions

62

co-ordination and monitoring of supplyissues as well as certain workforce vari-ables (workloads, practice management,productivity) (Brown 2001, Chisick 2001,Brennan & Spencer 2002, Brown et al.2002, Higgs & Richards 2002, Brennan &Spencer 2003). It is also necessary to anal-yse information on population factors tiedto oral health care, such as standard of liv-ing, dental needs, demand of services,percentage of population that is edentu-lous or elderly, impact of insurance plans,etc. In the United States and some EUcountries an excess of dentists in the1970s and 1980s led to the closure of den-tal schools (Committee on the Future ofDental Education 1995). There should bea movement from the emphasis in popula-tion/dentist to offer and demand issues. Inthis sense, a study of the European dentalworkforce in 1996 reported a mean ratioof 1,634 inhabitants per dentist for the EUoverall, and underlining that Spainshowed the highest ratio in the continent

(Anderson et al. 1998), should be inter-preted with care.To analyze the interactions betweendemand and offer (supply) is a compli-cated issue, and different authors deal bydifferent ways with this problem [for areview, see ref. (DeFriese & Barker 1982,Goodman & Weyant 1990, Bartholomewet al. 1991, Capilouto et al. 1995, Beazo-glou et al. 2002). If no control is imple-mented, some effects would occur,according to Llodra et al.:• Unemployment• Subcontratations: a dentist is contracted

to work as a hygienist• Reduction in the number of hours

worked per week, over treatment,reduction in quality, etc.

Since there are methods for quantifythe dentists needed, it should be consid-ered that, both, the excess and the insuffi-cient number of dentist, is inadequate,producing costs that are assumed by thesociety.

Figure 1. Ratio Population/Dentist in EU countries, from 1960-1998.

Pop./dentist (thousands)

Year

Spain

25

1960 1965 1970 1975 1980 1985 1990 1995 2000

20

15

10

5

0


63

Demand and supply

Since the concepts of workload and den-tist – the two main concepts behind – areessential, some limitations are expressedbelow:

The most commonly

applied measures ofdentist workload are the number of visitsprovided, hours worked and income (Gift1984, Petersen & Holst 1995). It has beensuggested that “visit” be used wheredentists are modelled as units with acapacity to supply a level of patient visitsper year (Shuman & Loupe 1994). Yetother authors argue that the dental visitvalue does not reflect the number andcomplexity of services per visit (Commit-tee on the Future of Dental Education1995), and that different dental proce-dures should be attributed different values(Council on Dental Health 1968). In Aus-tralia, between 1983 and 1993, it hasbeen reported a 18% reduction in thenumber of dentist attended per privatedentist, but maintaining the number ofworked hours, which indicates anincrease in the time per visit (Brennan etal. 1996), and a slight change in the ser-vices provided (Brennan et al. 1998).

Although the dentist

is usually consideredthe unit of analysis from the supply side,the characteristics of the clinical setting(general or specialised practice, rural orcity location, employment of dentalhygienists) (Brown et al. 1994; Brennan etal.1998; Grembowski & Milgrom 1990)may have a substantial impact on theactual service supplied. Some studies haveassociated personal characteristics such asage, sex, or having young children withthe hours per year worked (Boyle 1986,Spencer & Lewis 1988, Brennan et al.1992, Murray 2002).

Manpower application in Spain.

The increase of dentists in Spain hasreceived the attention from different per-spectives:• Studies evaluating the increase of den-

tists:Different studies, from the early 90s,have studied the number and distribu-tion of Spanish dentists and point to apossible excess of supply, aggravated bythe low mean age of the practitioners,which could lead to unemployment inthe future (.Noguerol Rodríguez et al.1990, Cordero Bulnes et al.1993, Fol-lana et al.1994, Noguerol et al.1999).These studies have not considered thedental needs in the population nor thedental demand

• Evaluation of the needed dentists. It ispossibly, the only approximation thatderived from the FDI/WHO methodol-ogy.Using the normative dental needs andthe FDI/WHO JWG6 computer program(a needs-based, demand-weightedmethod of workforce prediction appliedin other countries as well), an optimalpopulation/dentist ratio for Spain hasbeen estimated at 2,350 to 2,800 inhab-itants per dentist in 1993, and between2,700-3,200 in 2000 (Llodra Calvo et al.2002), figure already suppered, particu-larly in big cities. Yet if the current trendcontinues, the number of dentists will befar in excess of this optimal proportion.

• Evaluation of future trends.A 1996 Delphi prospective study con-ducted by the Spanish Dental Associa-tion (

Ilustre Consejo General deOdontólogos y Estomatólogos deEspaña

) gathered opinions from 82experts in different areas regarding the

64

future scenario of Spanish Dentistry upto the year 2005. A great increase in thenumber of dentists was foreseen, imply-ing increased economic pressure for theprivate dental clinics (Libro Blanco1996). It should be noted that whilemedical problems are treated mainlywithin Spain´s national public healthsystem, most people tend to resort tothe private sector for dental care, wherethe fee-per-service or fee-per-itemmethod of payment prevails.

• Analysis of workload per dentist. From1987 to 1997, it has been estimated a42% reduction in the number of privatevisits per dentist attended in Spain(Bravo 2002), as a proxy variable ofworkload per dentist.

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Bartholomew DJ, Forbes AF, McClean SI. Sta-tistical techniques for manpower planning.Chichester, West Sussex, England: John Wiley &Sons, 1991.

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Chisick MC. Predicting dental treatment work-load of U.S. military personnel.

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Colombet P, Bourgeois D, Vandeputte D.needs, demands and manpower balance. Den-tists/populations. FDI Commission 1996.

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Follana M, Noguerol B, Llodra JC, Sicilia A.Estudio continuado de las necesidades de aten-ción española. I. Demografía de la profesión den-tal española. 1993.

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vice requirements and supplies: the economicevidence.

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vices. En: Cohen LK, Bryant PS (eds). Social sci-ences and dentistry: a critical bibliography. Lon-don: Quintessence, 1984, pp 202-265.

Goodman HS, Weyant RJ. Dental health per-sonnel planning: a review of the literature.

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Higgs G, Richards W. The use of geographicalinformation systems in examining variations insociodemographic profiles of dental practicecatchments: a case study of a Swansea practice.

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Barcelona: Lácer, S.A., 1996.Llodra Calvo JC, Bravo Pérez M, Cortés Martini-

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Noguerol Rodríguez B, Follana Murcia M, SanzAlonso M, Bascones Martínez A, Sicilia FelechosaA. Dónde debo abrir mi consulta?

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Ugarte Ozcoidi M. Demografía de la ProfesiónDental Española 1998. RCOE 1999; 4 (Nº espe-cial): 17-232.

Noguerol Rodríguez B, Llodra Calvo JC, SiciliaFelechosa A, Follana Murcia M. La salud buco-dental en España. 1994. Antecedentes y perspec-tivas de futuro. Madrid: Ediciones Avances, 1995.

OECD. OECD Health Data 2000. A compara-tive Analysis of 29 countries. Electronic version.Paris: OECD Health Policy Unit and CREDES,2000.

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OECD. OECD Health Data CREDES 1996.Paris: OECD and CREDES, 1996.

Petersen PE, Holst D. Utilization of dentalhealth services. En: Cohen LK, Gift HC (eds). Dis-ease prevention and oral health promotion.Copenhagen: Munksgaard, Federation DentaireInternational (FDI), 1995, pp 341-386.

Shuman SK, Loupe MJ, Davidson GB, MartensLV. Productivity in Minnesota dental practiceswith increased visits by older patients.

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67

Oral Health Indicators: Major issues

Factors Influencing Demand and the Perceptions of Individuals, Dental Profes-sionals and the Funders of and Legislators for Oral Health Care in Europe

Kenneth A. Eaton

Surveillance, epidemiology and periodontal diseases

Denis M. Bourgeois and Pierre C. Baehni

The development of the extended youth consultation

Jaap P. Veerkamp

Oral Health-Related Quality of Life (OHRQoL): Review of existing instrumentsand suggestions for use in oral health outcome research in Europe


69

Factors Influencing Demand and the Perceptions of Individuals, Dental Professionals and the Funders of and Legislators for Oral Health Care in Europe

Kenneth A. Eaton

1

Introduction

Bradshaw (1972) considered that demandwas synonymous with expressed need.However, individuals may express need(s)and seek, but not receive, help. Whendemand results in utilisation of services, itcan be described as effective demand. Anumber of factors influence the threestages during which individuals becomeaware that they have a need for oral healthcare, whether or not they seek such careand then, whether or not they obtain it(becoming patients in the process). Indi-viduals, those who provide oral healthcare (the dental professionals) and thosewho fund and legislate all influence theprocess of converting need into effectivedemand. The majority of the factors influ-encing the first two stages relate to theindividuals (potential or actual patients).The influence of dental professionals,funders and legislators is more apparent atstage three. This paper will review the fac-

tors influencing demand and how demandfor oral health care is influenced by theperceptions of individuals, dental profes-sionals and funders and legislators.

Influences on and Perceptions of Individuals

The Andersen-Nyman Model

Several theories or models have been usedto explain why individuals use health andoral health care services. The social-psy-chological model proposed by Andersenand Nyman (1973) has been used widelyin hospital services and to some extent indentistry (Suominen-Taipale 2000). In themodel, three major groups of factors (pre-disposing, enabling and need-related) aresuggested. These are then sub-divided intosmaller groups. The model has been criti-cised on the grounds that it does notclearly differentiate between predisposingand enabling factors, puts too much

1. Adviser to the Council of European Chief Dental Officers, Ashford Kent. United Kingdom.

Paper adapted from PhD thesis “K. Eaton, Factors affecting community oral health care needs andprovision”. University of London. 2002.

70

emphasis on the use of formal health careand neglects informal health care andsocial support and that it only considersuse or non-use rather than extent of use(Pescosolido 1991). Notwithstanding thesecriticisms, the model can be considered asa useful template for consideration of thefactors concerned as they affect individu-als. It is used in this section together with aconsideration of the influences of socialand psychological factors on individuals’perceptions of need for oral health care.

Predisposing Factors

These may be sub-divided into those relat-ing to demographics and social structure(such as age, gender and marital status)and health beliefs/attitudes.

Demographics and Social Structure

Age, gender, marital status, ethnicity, edu-cational level, occupation and social classhave all been reported as influencingattendance patterns for oral health care.However, it is probably misleading toclaim that any one of these factors in iso-lation consistently has an effect on atten-dance patterns. Historically, in the UK, itappears that older people visited a dentistless frequently than the young or middle-aged (Todd et al.1982, Todd and Lader1991, Dental Practice Board 1992). Thismay well be the case in other countries(Suominen-Taipale 2000). However, theUK Adult Dental Health Surveys indicate adramatic change in self-reported atten-dance patterns amongst those aged over55 years during the 20 year periodbetween 1978 and 1998. In 1978, therewas a 32% self-reported attendance rate inthose over 55 years of age, the lowest for

any age group. By 1998, the 66% self-reported attendance rate for those agedover 55 years had become the highest forany age group (Nuttall et al. 2001). Duringthe same period the UK Adult DentalHealth Surveys indicated that the percent-age of over 55 year-olds without teethhalved for those aged between 55 and 74years and fell by a third for those over 75years (Kelly et al. 2000). Suominen-Taipale et al. (2001) reported that in twogroups of Finns, aged between 65 and 74years, number of teeth and income werethe principal determinants for dental visits.The perceived treatment needs and atten-dance patterns of older adults havereceived some attention in the UK in thelast decade. Tickle and Worthington(1997) studied two groups of 60-65 yearolds, one of which lived in an affluent areaand the other in a socially deprived area.Both showed similar perceived need fortreatment or advice but those from theaffluent area were significantly more likelyto attend the dentist on a regular basis. Theedentulous from both groups were lesslikely to attend regularly or to perceive aneed for advice or treatment. Lester et al.(1998) studied a group of houseboundadults aged 60 years or more and foundthat 93% attended for oral health careonly when they had problems.A number of studies have indicated thatfemales are more likely to be regular attend-ers for oral health care than males (Schwarz&Hansen 1976, Murtomaa 1983, Payneand Locker 1996, Kelly et al 2000) as aremarried people or those living together(Dolan et al. 1988, Österberg et al.1998).Ethnicity, ability to speak the language ofthe country of domicile and socio-eco-nomic deprivation can all influence percep-tions of need and attendance for oral health

Factors Influencing Demand and the Perceptions of Individuals

71

care (Widström & Nilsson 1984, Manski &Magder 1998, Kwan & Bedi 2000).Although social disadvantage is often asso-ciated with ethnicity (UK Census 1991) andpoor oral health (Beal & James 1970, Bediet al. 1991). Mandall et al. (1998) found thatamongst a group of socially deprived teen-agers oral health treatment need had a fargreater effect on their oral self perceptionsthan ethnicity. Furthermore, Corrigan et al.(2001) have implied that, if educationallevel and ability to speak and understandthe language of the country of domicile arediscounted, concepts of oral healthamongst those from ethnic minorities maynot differ from those with similar levels ofeducation and social status.

Health Beliefs/Attitudes

People need to believe that care personnelcan help them to achieve health (Kegeles1961). Without this belief they are lesslikely to seek help and, assuming that thehelp is available, change perceived needinto effective demand. Ettinger (1992) hassuggested that the development of attitudesto oral health can be influenced by eco-nomics, education and the environment inwhich the individual lives. A wide range offactors have been reported as influencingattitudes. Negative factors include: fear(Schwarz & Hansen 1976, Cohen 1987,Finch 1988, Davidson et al. 1999), lack ofperception of need (Cohen 1987, Finch1988, Davidson et al. 1999), laziness(Schwarz & Hansen 1976, Syrjälä et al.1992) and frustration with past care (Gil-bert et al. 1998). Positive factors include:putting a value on dental care (Petersenand Pedersen 1984), awareness of the pos-itive effect of oral hygiene instruction(Schwarz 1996) and a healthy life style

(Payne & Locker 1996). It is also interestingto note that one study has suggested thatpeople who attended for regular oral healthexaminations also demonstrate higher ratesof other positive health activities such asattending for regular routine medicalexaminations (Hayward et al. 1989). The1998 Adult Dental Health Survey includedface to face interviews with participants todetermine the oral health attitudes andbehaviours (Kelly et al. 2000). Reviewingthe results of these interviews, Bradnock etal. (2001) concluded that, in the UK, overthe previous three decades there had beena steadily improving approach towardmore positive dental health attitudes. How-ever, they also expressed an underlyingconcern that those who had the greatestoral health needs and those from moredeprived households still lagged behind interms of their oral health attitudes.

Enabling Factors

Cost

A variety of factors relating to cost havebeen reported as influencing demand. Thesystems used to finance oral health careappear to play a significant role. When den-tal insurance is available and the costs oforal health care are paid for by a third partydemand appears to be higher and thoseinsured visit dentists more frequently(Locker & Leake 1993, Brodeur et al. 1996,Manski & Magder 1998). However, theextension of dental insurance in Finlandand Norway did not increase utilisation ofservices by young adults in Finland (Arinen1992) or Norway (Grytten et al. 1996). Costfactors may well have a greater influenceon the utilisation of services by older peo-ple. A number of studies have indicated

72

that those without insurance visit a dentistless frequently (Dolan et al. 1988, Locker etal. 1991, Gift and Newman 1993, Gilbert etal. 1998). However, costs may be imaginedrather than true costs (Clerehugh 1986).Furthermore, Lester et al. (1998) found thata group of functionally dependent olderadults, who were likely to be exempt fromcosts, perceived costs to be a major barrierto seeking oral health care. A recent marketresearch survey in England found that lackof clarity about costs, due to poor commu-nication by dentists, was seen by some as adeterrent to seeking oral health care (Land2000). There have been conflicting findingsconcerning the influence of travel costs ondemand for oral health care in that Conradet al. (1987) and Mueller & Monheit (1988)reported that they had an adverse effect,whereas Kirkegaard et al. (1987) and Gryt-ten et al. (1993) found no such effect.

Supply of Services

It is unclear whether or not an increase inthe number of dentists, in an area or coun-try, is in itself a factor for increasing theprobability of visiting a dentist. In Sweden,Olsson (1999) reported that an increase inthe number of private practitionersincreased the probability of visiting a den-tist and also the number of visits. How-ever, Sintonen & Maljanen (1995) coulddetect no such effect in Finland in the1980s. Further studies in Scandinavia haveindicated that the practice of dentists send-ing recall appointments to their patientscan stimulate (or maintain) utilisation ofservices (Tuominen 1987, Sintonen & Mal-janen 1995). Seeking care from one (thesame) dentist over a number of years alsoappears to increase utilisation of services(Chen et al. 1997, Davidson et al. 1999).

In general, dentists work in towns and citiesand availability of oral care can be a prob-lem in rural areas. It is perhaps thereforeunsurprising that a number of studies fromvarious countries have indicated that peo-ple living in urban areas visit dentists morefrequently than those living in rural areas(Schwarz & Hansen 1976, Petersen 1983,Gift & Newman 1993, Gilbert et al. 1998).Andersen et al. (1995) have suggested thata number of primary determinants of oralhealth lead to oral health behaviour suchas effective demand (use) of available ser-vices. The system used to provide oralhealth care in a country is one such pri-mary determinant. Others include culturalcharacteristics of the population and fac-tors in the external environment, such aswater fluoridation and relative wealth.Previously, Andersen et al. (1970) had sug-gested that health service systems (includ-ing oral health service systems) consistedof three elements: policy (includingfinancing mechanisms and screening pro-grammes), resources (including personneland facilities) and organisation (includingco-ordination and control, regulations andlegislation). All three elements are invari-ably controlled by Governments or theiragencies and/or third parties, such as pri-vate or state insurance organisations.

There have been few multi-national stud-ies to compare the effects of systems fororal health care provision on oral healthbehaviour and effective demand. Report-ing on the

First International CollaborativeStudy of Oral Health Care Systems

(ICS 1),which was carried out in the mid 1970s,Arnljot et al. (1985) noted wide variationsin the systems. Sheiham (1995) com-mented that ICS1 showed that utilisationof dental services did not reduce dental


73

disease and that the availability and acces-sibility of even the best system did notensure good utilisation by the public. Asecond ICS was performed in the early1990s. The results indicated that, in thecountries concerned, the uptake of oralhealth care was related to the organisationand delivery of the local oral health caresystem (Chen et al. 1997).

Need-Related Factors

A number of studies have shown that thenumber of teeth in an individual’s mouthcan be one of the major factors influencingdemand. The edentulous or those with fewteeth visit a dentist less frequently than thedentate (Schwarz & Hansen 1976, Petersen1983, Gilbert et al. 1990, Gift & Newman1993, Joshi et al. 1996). Similarly, edentu-lousness appears to reduce the perceptionof need for care and so decreases demand(Gilbert et al. 1990, Schwarz 1996, Öster-berg et al. 1998). Tickle and Worthington(1997) reported that in a group of elderlypeople perceived need was influencedmost by being edentulous.A number of studies have reported thatindividuals who perceive a high need fororal health care contact a dentist more fre-quently (Gilmore & Kiyak 1985, Gilbert etal. 1990, Tennestedt et al. 1994).

The Influence of Social and Psychological Factors on Individuals’ Perceptions of Need for Oral Health Care

Traditionally, normative need for oralhealth care has been assessed in terms ofdisease-based measures of oral health inan approach derived from the medicalmodel, in which health is equated withabsence of disease (Sheiham et al. 1982).

This approach has been challenged and anumber of workers consider that a farbroader approach which takes intoaccount an individual’s functional, socialand psychological well-being should alsobe considered along with the pathologicalprocesses of oral disease (Cohen & Jago1976, Sheiham & Croog 1981, Reisine1985). An assessment of these factors canhelp to explain why individuals’ demandsfor oral health care, based on their percep-tions of need, differ from normative need.A number of studies have aimed to assessthe impact of oral disease on daily life andhave developed indicators. These includethe socio-dental indicator – the DentalImpact of Daily Living (Leao & Sheiham1995) and the Subjective Oral Health Sta-tus Indicator (Locker and Miller 1994).Mandall et al. (2000) have suggested thatthe concept of consumer-based measuresfor assessing oral health need may be par-ticularly relevant to aspects of oral healthcare involving aesthetics such as orth-odontics. Locker and Miller (1994) haveconsidered that such measures also have arole in targeting oral health care resources,so that they can be allocated to serviceslikely to produce the most health gain ingroups “disadvantaged with respect to oralhealth”. Apart from factors relating to indi-viduals’ perceptions of the impact of oraldisease on daily life, others such as fash-ion, media reporting and an increasingawareness of the importance of diseaseprevention may well influence individu-als’ perceptions of oral health care need.

Influences on and Perceptions of Dental Professionals

Cohen (1987) concluded that the factorsassociated with dental health profession-

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als, in the FDI’s classification of barriers todental attendance, had to be considered ifdentists were to provide accessible oralhealth care for patients. These barrierswere:• Inappropriate manpower resources• Uneven geographical distribution• Training inappropriate to changing

needs and demands• Insufficient sensitivity to patients’ atti-

tudes and needsFreeman (1999) has suggested that forgeneral practice these barriers must beconsidered in the same category headingsas those suggested by the FDI for individ-uals (actual and potential patients). Thus“inappropriate manpower resources” and“uneven geographical distribution”equate with “lack of access” in the list ofbarriers to individuals. “Training inappro-priate to changing needs and demands”equates to “lack of perceived need” and“insufficient sensitivity to patients’ atti-tudes and needs” to the influence of thepsycho-social factors for individuals of“anxiety and fear and financial consider-ations”. All of these barriers influenceeffective demand for oral health care.There have been a number of surveys ofthe public’s perception of dental profes-sionals. It seems that some of these per-ceptions cause patients to change dentistsand may deter some individuals fromseeking oral health care. Newsome andWright (1999) classified patients’ com-ments under five headings:- technicalcompetence, interpersonal factors, conve-nience, cost and facilities.

Technical Competence

Newsome and Wright (1999) concludedthat this was seen as a key determinant of

patient satisfaction in many studies. How-ever, although this may be the perceptionof dentists, people find it hard to assess thetechnical quality of services with anyaccuracy (Zeithaml & Bittner 1996). Astudy in which the quality of restorationswas assessed by dentists and patients con-cluded that simply practicing dentistrywith a high degree of expertise did notnecessarily convince patients that theyhad received high quality dental care(Abrams et al. 1996).

Interpersonal Factors

Communication skills, “caring” and infor-mation provision, including fully explain-ing procedures and costs, were the factorsmost commonly identified as being impor-tant to patients. In a recent survey in theUK, 90% of patients who responded, rated“care and attention” as very important,while the three other related factors of“pain control”, “dentist puts you at ease”and “safety conscious” were rated as veryimportant by 73% or more of respondents(Holt & McHugh 1997). In two large UKstudies, poor communication was a com-mon criticism by patients. This included alack of clarity about whether patients werebeing treated under NHS or private con-tract and no publicised scale of charges insome practices (Finch 1988, Land 2000).

Convenience

A number of studies have investigatedconvenience (Handelman et al. 1990,1996, Janda et al. 1996, Holt & McHugh1997). Factors assessed included afterhours clinics and nearness to shops andhealth centres. In general, this group offactors was not weighted as highly as


75

interpersonal skills. Janda et al. (1996)concluded that dentists should not empha-sise location and convenient parking butshould focus on professional competence,personality and attitude.

Costs

This topic has already been reviewed.

Facilities

In many studies this factor was not viewedby patients as very important. For exam-ple, “practice décor” was rated as the leastimportant factor by respondents (Holt &McHugh 1997). However, in one Ameri-can study comfort of seating in the waitingarea, magazine selection and backgroundmusic were shown to influence patients(Andrus & Buchheister 1985).

Influences and Perceptions of Funders and Legislators

Although patients frequently pay dentistsdirectly for their treatment and as suchcould be described as funders, in this sec-tion the term is used to describe third partyfunders. In terms of the provision of care,such third party funders include insurancecompanies (both private and state) andgovernment departments and agencies.However, although there are some totallyprivately funded dental schools, the edu-cation of dentists invariably takes place ininstitutions which are wholly or partiallystate funded. Governments also play a rolein setting regulations for the practice ofdentistry, through policymaking and legis-lation, even in countries where there isvery little publicly funded provision of oral

health care. Hence the term “legislators” isincluded in the title of this paper.The 1985 FDI general assembly consid-ered the problem of converting unmetneed for oral health care into demand andused the term “society” to describefunders and legislators. This is understand-able as funders and legislators are in effectthe representatives of society. Cohen(1987) reported that the FDI generalassembly considered that society couldcreate the following barriers to the conver-sion of unmet need for oral health careinto demand: • Insufficient public support of attitudes

conducive to health• Inadequate oral health care facilities• Inadequate oral health manpower plan-

ning• Insufficient support for research

The first barrier implies that the leaders ofsociety should promote an improvementin attitudes to health and oral health. Thesecond may well relate to the system forthe delivery of oral health care. The thirdmay be a result of poor oral health work-force planning and either training an insuf-ficient number of oral health care workersor training them inappropriately. Thefourth did not include education of theoral health care work force, which isdirectly related to workforce planning.However, most oral health care researchtakes place in or is co-ordinated by thestaff of dental schools. It can therefore beconsidered that there is a close relation-ship between education and research inoral health. In order to address these issuesreliable data are necessary. Two questionsarise: do these data exist and are they reli-able?

76

It is the role of the funders and legislatorsto try to minimise the barriers. The task ofaddressing the first barrier (changing pub-lic attitudes to health) inevitably leads tothe development and publication ofnational reports and strategies such as

Oral Health in America: A Report of theSurgeon General

(Department of Healthand Human Services, U.S. Public HealthService 2000). This sets out an action planto change the perceptions of the public,policymakers and health providers regard-ing oral health and disease so that oralhealth should become an accepted com-ponent of general health.

In some countries pressure to address theconsequences of the barriers may comevia the parliamentary process. However,oral health care competes for public fundswith all other aspects of health and otherpublic services and change may be slow,as may be the publication of the results oforal health surveys in scientific journals.For example, in the UK there were some564 parliamentary questions on dentistryduring the 1994/95 session, of which 307related to access to oral health care foreither individuals or populations (Sarll2001). A number of studies includingAllen et al. (1992) had reported on the per-ceptions of patients that access to NHSoral health care was poor in some parts ofthe country. This view was reinforced by apostal survey carried out at the end of1994 (Falcon & Hurst 1998). A further sur-vey, carried out in the summer of 1999,indicated no improvement (McGrath et al.2001). An estimated two million peoplewere identified as having unmet demandfor primary dental care in 2000 (Depart-ment of Health 2000). In response theGovernment have implemented a plan

which incorporates a number of initia-tives, including the establishment of den-tal access centres (Department of Health2000) and is conducting a review of theoral healthcare workforce.Although membership of the EuropeanUnion (EU) does not require states to mod-ify their health care systems, Widström(2000) has suggested that in the long runthere will be pressures for social andhealth policies to be co-ordinated. It istherefore important that dental profession-als and planners have a clear understand-ing of the systems for the provision of oralhealth care and their relative costs in thedifferent member states of the EU. There isalso freedom for EU citizens to work any-where in the Union suggesting that work-force planning should therefore be con-ducted at a European as well as a nationallevel. For seven professions this freedomof movement is supposedly “under-pinned” by comparable training standardsin each member state.

Conclusions

A range of factors which have little to dowith biology or pathology have influencedthe prevention, diagnosis and treatment oforal diseases. They include national andlocal policies, costs, health beliefs and theattitudes and education of dental profes-sionals and the public. The review set outin this chapter indicates that factors relat-ing to demand for oral health care havebeen comprehensively studied. There havealso been large numbers of epidemiologi-cal studies to assess normative need,which have historically been used as abasis for planning oral health care provi-sion. There is now a view that social andpsychological factors should also be taken


77

into consideration when such planningtakes place. A number of questions, whicheffect policy makers and legislators at alllevels (local, regional, national and Euro-pean), should be considered. They relate tothe reliability of epidemiological surveysand to the availability and quality of infor-mation on the following European issues:the comparison of systems for the provi-sion of oral health care and the cost of thisprovision, oral health care workforce num-bers and the education of members of thedental workforce. The problems relating tothese issues are set out in the next section“statement of the problem”.

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81


Denis M. Bourgeois

1

and Pierre C. Baehni

2

Introduction

In the 1970s, the natural history of peri-odontal disease involved accumulatingdental plaque, causing tartar, leading tothe formation of pockets, with bone losscausing loss of teeth. Everyone wasdeemed to be exposed to periodontitis.Deficient hygiene and age were major riskfactors.Burt (1993) sums up the concept prevail-ing at the time:• Gingivitis develops into periodontitis,

with associated destruction of bone tis-sue and possible tooth loss.

• All subjects are exposed to periodonti-tis, which may develop to the point ofaffecting the teeth. The severity of peri-odontitis increases with age.

• Periodontal disease is the main cause oftooth loss after the age of 35.

Our knowledge of periodontal disease hasmade great progress over the last few years

(Baehni & Bourgeois 1998, Hancock &Newell 1993). It has in part been epidemi-ological data which have opened up newhypotheses regarding etiology, pathogen-esis and management (Armitage 1996).New descriptive and analytic epidemio-logical methods – associated risk factorquantification, in particular – have playeda role in improving the model. Microbiol-ogy studies have pinpointed the role ofcertain specific bacterial strains. Newexplanations have been put forward as tohost-response and resistance.Clinical research has come up with newtreatment strategies to slow down diseasedevelopment and to reconstruct the peri-odontal structures. Epidemiology has fur-ther enabled the distribution of periodon-titis in various populations to be measuredand certain risk factors to be identified(Beck 1990).Among such risk factors, we can distin-guish the innate and the acquired. Innaterisks factors include gender, genetic fac-

1. Faculty of Dentistry, University of Lyon, France.2. European Federation of Periodontology, University of Geneva, Switzerland.

Paper issue from a version presented in Encycl Méd Chir, odontologie, 23-444-A-10, 2002.

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tors, congenital immune deficiency,phagocyte dysfunction and syndromessuch as Down’s syndrome. Poor hygiene,age (Ajwani & Ainamo 2001), certainmedical drugs, smoking (Berstrom et al.2000, Hashim et al. 2001), acquiredimmune deficiency, acquired endocrinedisorder (Meyle & Gonzales 2000), stress,and nutritional factors figure among theacquired or environmental risk factors.It has recently been suggested that milduntreated periodontitis constitutes a riskfor general well-being and health, espe-cially with respect to cardiovascular(Armitage 2000) and respiratory disorder,pre-term birth (Offenbacher 1996), anddiabetes (Katz 2001). Current epidemio-logical findings have indeed pointed to alink between such risk factors and peri-odontal affections, but any causal relationas such still needs to be posited with thegreatest caution.It is also worth highlighting certain specific-ities of epidemiological research as com-pared to clinical studies and case reports:• it is groups rather than individuals

which are focussed on;• subjects both with and without relevant

conditions are included, the study aimingas it does at risk assessment (AAP 1996).

Methodological issues

Classification

Classification of periodontal disease hasdeveloped greatly over the last few years(Kinane 2001). The 1993 European Peri-odontology Symposium deemed the clas-sification unsatisfactory as it then was,especially inasmuch as different patholo-gies presented important areas of overlap(Armitage 2000). There was also noted to

be a lack of precise information on treat-ment quality, patient acceptance and tis-sue response – especially as regards treat-ment-resistant periodontitis (Attström &van der Velden 1994).Changes in the classification of childhoodand teenage periodontitis are typical here.Saxen noted in 1980 that only the formlocalised in the incisors and first molarsrepresents acute juvenile periodontitis as aclinical entity. It has recently been sug-gested that the distinction between earlyand adult-onset periodontitis is mainlyepidemiological, based on the observa-tion that periodontitis is less frequent inyoung children and young adults (Tonetti& Monbelli 1999). And finally, diagnosesof localised juvenile periodontitis, genera-lised juvenile periodontitis or epithelialattachment loss are now classified asaggressive periodontitis (Najib 1997).The recent 1999 Workshop for a Classifi-cation of Periodontal Diseases and Condi-tions (AAP 1999) altered the previous1986 American Academy of Periodontol-ogy (ADA 1998) classification, which haddivided periodontitis between:• aggressive periodontitis – previously

known as early onset periodontitis(EOP).

• necrotizing periodontitis• periodontitis associated with systemic

disease• adult periodontitis.

Case definition

In theory any epidemiological studyshould be founded on an updated andstandardised definition of the pathology inquestion. In periodontology, unfortu-nately, no such definition exists, and thecriteria have not been definitively laid


83

down. Epidemiological studies havedeployed a variety of clinical parameters,such as gingival inflammation signs, pocketdepth on probing, measurement of loss ofattachment, or bone loss on X-ray. Diag-nostic criteria tend to vary from one authorto another. And then there is a wide varietyof terms used to define a periodontalpocket as “deep” or “pathological” or againto define the “level of clinical attachment”.And finally, there is no agreement on howto define the various categories of peri-odontitis (e.g., aggressive periodontitis).Moreover, the number of surfaces whichneed to be affected for a subject to countas a clinical case – i.e., as suffering fromperiodontal disease – varies greatly fromauthor to author. Such incoherence obvi-ously vitiates data on the distribution ofthe disease (Papapanou 1996).Diagnostic criteria often differ from oneauthor to the next. Examination conditionsare variable. There is also a clear confu-sion in the utilisation of data between therelatively few epidemiological studies inthe literature on the one hand and clinicalresearch on the other.

Recommended case definition

The various forms of periodontal diseasesare of infectious origin. Most present aschronic disease with a slow developmentwhich is irreversible in the advancedstages even if the infectious agent hasbeen eliminated. The pathology is furthercharacterised by repeated attacks, oftenaffecting several sites neighbouring one ormore teeth. Finally, the developmentalpathway of the disease is not currentlywell established, which leaves many prob-lems in measuring the active phase and incase definition (Beck & Löe 1993).

Number of sites measured

The previous concept of universal expo-sure has given way to one of

individual

exposure. Since periodontal disease hascome to be seen as site-specific, cliniciansand researchers have stressed the impor-tance, from the point of view of the naturalhistory of the disease, of monitoring asmany different sites as possible so as tooptimise the chances of detecting the dis-ease under way. A broader case definitionis in terms of one or more sites with at least2 mm loss of attachment (NIDR 1987).The most commonly monitored sites areproximo-vestibular, disto-vestibular, medio-vestibular, proximo-lingual, disto-lingual andmedio-lingual. Cost, patient impact and intra-and inter-examiner variability, however,need to be taken account of. Priority shouldbe given to directly visible sites, so as betterto control for intra- and inter-examiner vari-ability (Kingman 1991). Underestimation ofprevalence does not seem to be directly pro-portional to the insufficiencies of measure-ment, inasmuch as certain sites are more lia-ble to become sensitive to proximal anddistal periodontal pockets and to medialrecession than are others.It is to be borne in mind that linear mea-surements of specific sites may fail to rep-resent the true extent of the root’s loss ofconjunctive attachment. They are at best arecord of disease history, and make no dis-tinction between an on-going destructiveprocess and a situation which has stabi-lised itself (ADA 1998).The ability of partial recording to reflectthe overall mouth situation is to be under-lined. The logic of epidemiology calls forsimplified partial indices (Barnes 1986).The WHO recommends data recording bysextant. The prevalence of subjects with at

84

least 4 mm attachment loss is probablyunderestimated by 13% in general or par-tial examination. In Diamanti-Kipioti etal.’s study (1993), the partial recordingsystem found a mean 3.2% of deep pock-ets per subject, and 19.5% of subjects withat least one such pocket, as against 5.0%and 47% respectively per overall record-ing of all the circumference.

Impact of missing teeth

Tooth-loss may be the terminal result ofdestructive periodontitis. Teeth lost as asequela of disease tend not to be recordedas such, which leads to significant under-estimation of prevalence and severity.Tooth-loss risk factors fail to be identified,and the role of periodontal disease under-lying extraction is not fully acknowledged(Papapanou 1996).

Natural pathology studies

Longitudinal descriptive studies are rare,which – over and above a failure todescribe the natural history of periodontaldiseases – underscores the difficulty ofestimating incidence. Research needs tobe supported in view of the current issuesconcerning such diseases.Beck and Koch (1994) studied the progressof attachment loss over a 3-year period ina sample of elderly persons in North Caro-lina. 13.2% of sites with deep pockets atthe start of the study showed at least 3 mmattachment loss over the observationperiod, whereas only 4.7% of sites withpockets shallower than 3 mm presentedattachment loss. The authors argue for aprocess of attachment loss by randomisedactive phase; sites losing 3 mm of attach-ment or more over the first 18 months of

the study were no more liable to lose 3 mmor more over the following 18 months thanwere sites which had undergone no attach-ment loss during the first period.

Indices

There is no consensus in the literature asto recommendations for the use of a repre-sentative epidemiological index of theperiodontal situation (Baehni & Bourgeois1998). Barnes (1986) listed and categor-ised the proposed indices under signs,symptoms and associated etiological fac-tors, and concluded that, in 1986, therewas no satisfactory public health indexable to provide objective information as todistribution, prevalence, incidence andtreatment needs in populations. Given thevariety of indices used in periodontologyover the last 20 years, comparisonsbetween the available data are hard todraw (Skrepcinski & Niendorff 2000).Present-day epidemiology assesses peri-odontal disease with periodontal indicesmeasuring pockets and recording bone-losson X-ray (Gilbert 1994). Pocket measure-ment provides reproductible quantificationof periodontal destruction in internationalunits (mm). Variation due to factors such astype of probe, pressure exerted, stage ofpathology, examination site, or inter-exam-iner error, make standardisation and cali-bration necessary (ADA 1998).Use of the Community Periodontal Indexof Treatment Needs (CPITN) (Ainamo1982) to assess prevalence of periodontaldisease is controversial and indeed con-sidered inappropriate by the scientificcommunity (Baelum & Papapanou 1996).Such partial recording indices underesti-mate prevalence and severity (Papapanou1996). Thus, Locker et al. (1998) excluded


85

publications using this index from their1998 review of epidemiology and peri-odontal disease in older adults. The mainobjection is that the CPITN’s partial meth-odology seriously underestimates theprevalence and severity of periodontalpockets in adults, failing as it does todetect a substantial proportion of affectedsubjects (Baelum 1996). Likewise, CPITNscores do not correlate strongly withattachment-loss scores, but tend to overes-timate prevalence and severity in younger(15-29 year-old) subjects and to underesti-mate them in the older (over 50) popula-tion. Nevertheless, this index presentlyremains the WHO reference, enjoying itsown standardised international data banksince 1982, with 1,000 references (Baehni& Bourgeois 1998).The clinical attachment level is the verti-cal distance (in mm) from the enamel-cement junction to the clinical periodon-tal attachment point. Carlos et al. (1983)propose an Extent and Severity Index (ESI).“Extent” represents the proportion ofexamined sites presenting a clinicalattachment level of a given threshold(classically, 2 mm or more); “severity”represents the mean level of clinicalattachment per subject per site presentingthis threshold.Attachment loss represents the differencein clinical attachment measurements attwo points in time, indicating the degreeof additional loss during that interval.Bone loss represents the total vertical lossof alveolar bone at the proximal or distalsurface of the tooth, expressed in mm or asa percentage of the total root length (Papa-panou & Tonetti 2000). Like attachmentlevel, attachment loss and bone loss canbe expressed in terms of extent and sever-ity.

Attachment loss indices have becomepopular in periodontal epidemiology;methodological research in 1995 and1996, however, showed that the extentand severity of attachment loss varied sig-nificantly according to the tooth or the sitemeasured, the type of probe used (Papa-panou et al. 1993, Mayfield 1996), andeven the method of analysis. In methodsused for national-level screening for pock-ets and attachment loss, sensitivity variedfrom 0.24 to 0.87 in high-prevalence pop-ulations (Fox 1992).Inter- and intra-examiner quality and vari-ability, rarely gone into in the literature,doubtless represent the most critical pointwith respect to this index, especially whenused for data collection by site, with a pos-sible 32

×

6 = 192 sites. Certainly valid ina context of clinical research, its useful-ness – given its reliability and the costsinherent in its deployment – remains to beproved as far as population-based studiesare concerned.

Recommended surveillance (WHO)

The reference method uses WHO recom-mendations with an exploratory-type sam-pling method. This is a stratified clustersurvey technique intended to include themain population sub-groups liable to beaffected to one degree or another and tocover a standard number of subjects perage-group, whatever the location. Suchexploratory surveys may be classified asnational, regional or local pilot studies.The exploratory method is based on strati-fied sampling, including the main popula-tion sub-groups presenting differentdegrees of disease. This method provides afast and economic means of estimating theoverall prevalence of periodontal diseases

86

in the population and identifying themajor variations in severity among the var-ious subgroups.In countries with well-developed dentalhealthcare systems, data are collectedfrom sentry sites, dental clinics, insurancecompanies and national health informa-tion systems.In communities with little or no dentalhealth care, special community surveysare called for. A 5-year period is recom-mended for harvesting information at anational level.

Minimum information collection

Aggregate data

Attachment loss (WHO 1998)

Pocket depth gives an indication of theextent of periodontal attachment loss. Butthis measure is unreliable in case of gumretraction. When the enamel-cement lineis not visible and the upper value of thecommunity periodontal index for a sextantis less than 4, any periodontal attachmentloss for the sextant in question is estimatedat less than 4 mm. The degree of attach-ment loss is recorded in terms of the fol-lowing codes:0 – Periodontal attachment loss 0-3 mm

(enamel-cement line invisible, andcommunity periodontal index 0-3)

If the neck of the tooth is not visible andthe community periodontal index equals4, or if the neck is visible:1 – Periodontal attachment loss 4-5 mm2 – Periodontal attachment loss 6-8 mm3 – Periodontal attachment loss 9-11 mm4 – Periodontal attachment loss 12 mm or

more

x – Sextant not included (less than 2 teethpresent)

9 – Data not recorded (enamel-cementline is neither visible nor discernable)

Community periodontal index (WHO 1998)

Three periodontal status indices are usedfor this assessment: bleeding gums, tartarunder the gums, and periodontal pocket.A light CPI probe, with a 0.5 mm sphericaltip and marked with a black band atbetween 3.5 mm and 5.5 mm and blackrings at 8.5 mm and 11.5 mm from the tip,is used.Sextants. The mouth is divided into sex-tants, defined by the teeth numbers: 18-14, 13-23, 24-28, 38-34, 33-43, and 44-48. A sextant is only to be examined if itcontains at least 2 teeth which are not duefor extraction.Index teeth: in subjects under 20 years ofage, only 6 index teeth are examined: 16,11, 26, 36, 31, and 46. In children under15, only bleeding and tartar deposit aretaken into account. In adults over 20, theteeth to be examined are: 17, 16, 11, 26,27, 36, 37, 31, 46, and 47. The 2 posteriorsextant molars are coded together and, ifone is missing, it is not replaced. If there isno index tooth present in a given sextant,all the remaining teeth in it are examinedand the upper value attributed to the sex-tant. The distal sides of the third molars arenot assessed.Codes for examination and data recording:0 – Healthy tooth1 – Bleeding detected on exploration2 – Tartar detected during exploration,

but the black band of the proberemains perfectly visible

3 – 4-5 mm pocket4 – 6 mm pocket or greater


87

X – Sextant not taken into account (lessthan 2 teeth present)

9 – Data not recorded

Case data for survey and notification

The information needed for effective andusable assessment of periodontal diseasesprevalence relates to:• Year of study, number of cases, region

and population covered by the survey,information quality level (national,near-national, regional, local, informa-tive), type of locality (urban, suburban,rural)

• Reference age-groups: i.e., 12 years(sub-gingival tartar and bleeding only),15 years (sub-gingival tartar and bleed-ing only), 35-44 years, 65-74 years.

Recommended data analysis, presentation and reports

(Benamghar et al. 1994)

• Percentage of subjects showing healthyperiodontal tissue; percentage of sub-jects showing bleeding only; percent-age of subjects showing tartar only; per-centage of subjects showing 4-5mmpockets; percentage of subjects show-ing deep (at least 6 mm) pockets.

• Mean number of sextants with healthyperiodontal tissue, bleeding or highervalue, 4-5 mm pockets or higher value,and number of sextants excluded fromexamination.

• Number and percentage of subjectswith attachment loss per highest score

• Mean number of sextants with attach-ment loss per highest score, mean num-ber of sextants excluded from examina-tion, and number of unrecorded sextants.

• Morbidity per age-group, ethnic group,place of residence, and type of locality.

Main uses of the data generated

• Assessment of the scale of periodontalproblems at national, regional and locallevels.

• Identification of population needs withregard to prevention and treatment forperiodontal problems.

• Providing information on severity anddevelopment of disease, and an idea ofwhether it is increasing or diminishing.

• Identification of high-risk sub-groups.• Assessment of how far existing dental

health care services meet current needs.• Assessment of type and scale of preven-

tion and/or cure services required.• Resources needed to set up, maintain

and extend or reduce dental health pro-grammes, including an estimate of thenumber and type of personnel required.

General results

Overall

New concepts have emerged from thedevelopment of epidemiological research.In the present state of the art, they may besummarised as follows:• adult periodontitis is a multi-factor

disease;• periodontitis is caused by specific

bacteria;• the host’s immuno-inflammatory response,

while protective, leads to destruction oftissue;

• periodontitis develops over phases ofattachment loss;

• sensitivity to periodontitis varies acrossindividuals;

• innate and environmental risk factorscontribute to sensitivity to periodontitis.

88

Gingivitis

Gingivitis varies widely from one study toanother. Such differences are probablymore a matter of methodology than of realdifferences in the disease itself (Jenkins &Papapanou 2001). Gingivitis is wide-spread. Prevalence, severity and extent inyoung subjects increases with age, begin-ning with milk-teeth, reaching a peak atpuberty, and then declining somewhatduring adolescence.Cutress et al. (1986) found that 96% of aNew Zealand sample of 15-19, 25-29 and35-44 year-olds presented gingivitis. Gingi-vitis was found in 34% of all sites exam-ined. Ganghwin et al. (1999) found a prev-alence of 85% in 5-6 year-olds in Australia,and 24% in 6-74 year-olds. In the USA,14% of 6-11 year-olds and 32% of 12-17year-olds presented gingivitis, the percent-age in adults varying from 29% in youngerto 13% in older subjects (Albandar & King-man 1999, Jenkins & Papapanou 2001).Brown and Löe (1993), working fromnational probabilistic studies in the USand Denmark, reported 60% prevalencefor teenagers and 40-50% for adults. Only5-6% of gum sites showed inflammation.In comparison with studies dating from the’50s and ’60s, they suggest gum health isimproving, possibly due to the improveddental hygiene observed in industrialisedcountries as a whole, but also in a contextin which no scientific or methodologicalguarantees exist.

At population level, the incidence of den-tal plaque and gingivitis is appreciablyhigher in boys than girls. Improved dentalhygiene seems to have reduced gingivitisin a number of industrialised countries.Overall, available epidemiological data

do not enable the hypothesis of a reduc-tion in periodontal disease to be con-firmed, due to a lack of perspective on thenatural development of these pathologies(Papapanou 1996).

Early-onset periodontitis

Epidemiological data on childhood, teen-age and early adult periodontal diseaseare scarce, and the methodological con-text is precarious. There has in fact beenno recent epidemiological programmethat might serve as a reference for the val-idation of epidemiological hypotheses.Regarding milk-tooth periodontitis, dataare limited. Jenkins and Papapanou (2001)suggest a rate of 5% in Caucasian chil-dren. Only a few sites were affected, andattachment and bone loss were variable.Very rarely, severe generalised periodonti-tis can affect milk teeth. Such cases areclassically associated with major systemicdisorder.Loss of periodontal support due to peri-odontitis is the norm among most teenag-ers. This tends to be a matter of minorattachment or bone loss. Early periodonti-tis shows a 0.1-3.4% prevalence amongyoung adults (Wisner-Lynch & Giannobile1993). It is thus relatively infrequent in thepopulation as a whole (Papapanou 1996).In the USA, prevalence at 14-17 years isbelow 1%, and reaches 3.6% by 18-34years of age (Oliver & Brown 1993).Localised early-onset periodontitis is 4times as frequent as generalised early-onset periodontitis. The proximal surfacesof the first molar are the sites most fre-quently affected by periodontitis and pro-gressive destruction.Non-normal periodontal destruction hasbeen noted in teenagers. Stabholz et al.


89

(1998) reported 38.4% prevalence in aspecific Israeli population. Such differ-ences are attributed to race, ethnicity,variations in available preventive dentalhealth care, and gender (Wagaiyu &Wagaiyu 1992). Thus, localised juvenileperiodontitis is considered to be higher innon-industrialised (0.3%) than industria-lised countries (8%). Prevalence andextent of attachment loss were greater inIndo-Pakistanis than in Caucasians (Clere-hugh 1993).Necrotizing periodontal disease peaks inyoung adults, but is infrequent in industri-alised countries, although found more fre-quently in HIV-positive subjects than inthe population as a whole. In non-industri-alised countries, young children alreadysuffering from infection and malnutritionare at high risk of necrotizing periodontaldisease with possible loss of facial tissue.Finally, smoking has been identified as arisk factor for periodontitis in youngadults.

Adult periodontitis

Moderate attachment loss has beenreported in a relatively high percentage ofadults and elderly persons, severe lossbeing confined to a minority of subjects.Severe loss is further limited to a few sites,and is found to affect only a certain pro-portion of these sites on examination (Burt1994). Some 1 in 5 adults present moregeneralised attachment loss. The rate ishigher among older subjects. Similar find-ings apply in the case of bone loss (Lockeret al. 1998.The few incidence studies suggest that 50-75% of adults experience attachment lossin at least one site over relatively shortperiods (Burt 1994, Norderyd & Hugoson

1998, Hugoson & Laurell 2000). How-ever, relatively few sites examinedshowed additional loss, so that – despitethe high incidence rates – extent andseverity remain low.Many factors have been found to be asso-ciated with incidence and prevalence.Most are more to be considered as riskmarkers than as risk factors as such. Atpresent, the evidence that smoking andparticular periodontal pathogens play acausal role is stronger than for most othersuggested risk factors (Berstrom et al.

2000

).

Most studies world-wide report a 10-15%prevalence for severe periodontitis,defined as 6 mm or more attachment losson one or more sites. The main changewith respect to the previously describedmodel is that 5-20% of the population suf-fers from a severe generalised form, evenif a mild form of the disease affects mostadults. Severe forms are more commonlyfound in young adults.Estimates of 80%, however, have beenmade for certain regions, although it can-not be affirmed that such diversity is realand not an artefact of methodological biasin sampling or examination.In the USA, moderate periodontitis, withone or more sites presenting at least 3 mmattachment loss, was estimated at 44% at16 years of age, and at 80% between 18and 64 years. Advanced periodontitis,with one or more sites presenting at least5 mm attachment loss, also dependedupon age, and affected 13% of the popu-lation. In the USA, this rate means at least20 million people affected by advancedperiodontitis. On the basis of a nationalstudy run from 1988 to 1994, with a strat-ified sample of 9,689 persons aged

90

between 30 and 90 years, Albandar andKingman (1999) estimated that 23.8 mil-lion persons had at least one dental sur-face with at least 3 mm recession; 53.2million had gum bleeding; 97.1 millionhad tartar; and 58.3 million had sub-gingi-val tartar: i.e., 22.5%, 50.3%, 91.8%, and55.1%, respectively. In Europe, the preva-lence of severe forms never exceeds 9%(Hescot & Bourgeois 1999). In France, the1993 reference study for the 35-44 yearage group found that 12.5% of that popu-lation had a healthy periodontium, 27%had periodontal pockets of between 3 and5 mm, and 2% had severe forms withmean sextant damage of 1.3 (Bourgeois etal. 1997).The periodontal health of the 65-74 yearsage-group depends strongly on the rate ofedentulousness, which varies widely fromone country to another in Europe (12.8%in Italy, 16.3% in France, 58% in the U.K.,and 65.4% in the Netherlands) (Bourgeoiset al. 1998).

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European Workshop on Peri-odontology. London: Quintessence PublishingCo., 1994: 120-126

Baehni PC, Bourgeois DM. Epidemiology ofPeriodontal Health and Disease. Proceed. Euro-pean Workshop on Mechanical Plaque Control.Lang, N.P., Attström, R., Löe, H. eds. Quintes-sence Publishing Co, Inc. Berlin. 1998: 19-34

Baelum V, Chen X, Manji F, Luan WM, Fejer-skov O. Profiles of destructive periodontal diseasein different populations.

J Periodontal Res

1996;31: 17-26

Baelum V, Papapanou PN. CPITN and the epi-demiology of periodontal disease.

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1996; 24: 367-368Barnes GP, Parker WA, Lyon TC, Fultz RP. Indi-

ces used to evaluate signs, symptoms and etio-logic factors associated with diseases of theperi-odontium.

J Periodontol

1986; 57: 643-651Beck JD. Methods of assessing risk for peri-

odontis and developing multifactorial models.

J Periodontol

1990; 65: 468-478Beck JD, Koch GG. Incidence of attachment

loss over 3 years in older adults – new and pro-gression lesions.

Community Dent Oral Epide-miol

1995: 23: 291-296Beck JD, Löe H. Epidemiological principles in

studying periodontal diseases.

Periodontol 2000

1993; 2: 34-45Benamghar L, Bourgeois D, Leclercq MH, Mc

Combie J, Barmes DE. Standard descriptive tablesin WHO Oral Health.

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Berstrom J, Eliasson S, Dock J. A 10-year pro-spective study of tobacco smoking and periodon-tal health.

J Periodontol 2000

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conditions in 35-44-yr-old adults in France, 1993.

J Periodontal Res

1997; 32: 570-574Bourgeois DM, Nihtila AM, Mersel A. Preva-

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Brown LJ, Löe H. Prevalence, extent, severityand progression of periodontal disease. Periodon-tol 2000 1993; 2: 57-71

Burt B. The role of epidemiology in the study ofperiodontal disease.

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1993;2: 26-33

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93


Jaap P. Veerkamp

1

Introduction

In the Netherlands the preventive efforts ofthe last twenty years have resulted in alarge reduction of dental caries prevalencein children. This achievement howeverresults in cutting back the finances usedfor the national preventive campaigns.This project deals with the idea to reallo-cate the finances for preventive measuresand its long term consequences.

Nowadays the 12-yr old Dutch children areamongst the dentally healthiest of Europe.The quality level of the teeth of the 5-yr oldshowever lies far behind that of their 12-yrold counterparts (Kalsbeek et al.1994, Kals-beek et al. 2000). The increase of dentalcaries in this young group seems to be visi-ble in more western European countries(Haugejorden 2002). Between 1994 and2000 the number of caries free 5-yr old chil-dren in the Netherlands went down from55% to 51% and in the caries group the dsfigure went up from 2 to 3, a 50% raise,where the percentage of restored teeth wentdon from 25% to 12%, a 50% reduction.

Now it can be hypothesized that the dentistgeneral practitioner (GP) has an increasingdifficulty in treating children. On the otherhand it has been assessed that the dentalsituation at the age of 4-5 years is a predic-tive measure for the relative caries risk ofchildren (Roeters 1992, Billings et al. 1994)and has to be considered as a starting pointfor further monitoring of its preventive mea-sures. Children’s poor dental health in thepast led to a number of clearly well struc-tured preventive measures.Those measures (fluoride applications and– rinsing, group instructions, nationalcampaigns and the use of fluoridatedtoothpaste) gave a maximum effect. Thoselarge scale measures are a relatively sim-ple and not expensive method to createresults in large groups of people. Whenthe dental health of the group increasesthe 80/20 rule will apply: with an original20% effort an 80% result can be achieved.To reach the last 20% of the result, 80% ofthe effort is needed.Preventive measures do minimise the mor-bidity, but increase the costs of national

1. Academic Centre for Dentistry Amsterdam (ACTA), The Netherlands

94

health. In the discussion on nationalhealth the comparison can be positivelyinfluenced by a better identification ofgroups at risk for illnesses and replacegroup measurements with individual strat-egies when the group measurements arenot cost effective anymore. In the dentalsituation we do need an individual cariesrisk assessment. This will only be possiblewhen the groups that need this increasedattention can be identified (Powell 1998).Nowadays dentist it expected to “givesadequate information that is based on up-to-date scientific knowledge, informingthe patient sufficiently enough for aninformed consent” (Raadgevend Comité2000). Translated to preventive measuresthe dentist should be able to answer ques-tions like “How many cavities will mychild have?” or “How many of those cavi-ties can you prevent?” or, finally: “Whatare the costs of your preventive measuresto prevent one cavity?”Research shows us that the dentist’s clini-cal estimate of the condition of a person’steeth differs widely. Variation in nominat-ing a child “at risk” differs between den-tists up to three times based on their clini-cal view (Alanen et al. 1994). For thepatient this is difficult to understand, nomatter he is in the group of false positivesor false negatives (van Loveren enVeerkamp 2002).

Introduction of the EYC (Extended Youth Consultation)

Let’s go back to the preventive dentalmeasures. When group preventive mea-sures have to turn into individual preven-tive strategies, we will need to identify thegroups that are likely to develop dentalcaries. The matter has been studied exten-

sively. This report focuses on the addi-tional diagnostics tools that are needed,for instance by changing the half yearcheck-up into a yearly extended youthconsultation (EYC) to identify the childrenat (dental) risk.In a committee, organised by the DutchDental Association (Nederlandse Maat-schappy Tandheelkunde, NMT), the mat-ter was studied extensively. Logistical andfinancial consequences were studied by atask group (POJG) and a test model wasdeveloped and applied in a try out project.The committee was asked to study on thefollowing:• Assessment of the dental risks for the

child’s developing teeth that need fur-ther adjustment within a check-upperiod.

• How can the GP positively influencethese dental risks?

• How often should the dentist see a childat risk to prevent further deterioration oreven to improve the quality of thechild’s teeth

• Can this be achieved by a yearly, moreextensive check-up?

• Will a yearly check-up interval not beharmful for the children’s teeth?

The condensed aim of the evaluative studywas to see if the caries risk could beassessed using appropriate parameters

totransfer the finances, (unnecessarily)spend to the healthy group, to the groups/individuals at risk

.

Age and dental risk periods: the Milky Way

In the development of the child’s teethsome repetitive aspects occur, needingclose monitoring (e.g. oral hygiene). Someare related to growth and development of


95

the child, needing continuous attention,some others occur incidentally, but mostlywithin rather demarcated periods (e.g.nursing bottle caries, developmental dis-turbances in the first molars). After treat-ment they do not need further attention.Some of those aspects are important

parameters for the caries risk assessmentof the child. The use of the parameters canbe put into protocols.Risk is an age related phenomenon. In theMilky Way schedule below the quiet peri-ods can be found. The “red” periods willcreate a higher number of children at risk.

Individual criteria for dental risk

Using direct criteria the dental risk can beassessed easily. Evidence based criteriaare:•

Prevention:

level of personal preventivecare. Brushing with fluoridated tooth-paste works (Backer Dirks & Kalsbeek1987). Without dental plaque no carieswill occur, but solely brushing does notsuffice. (Bellini et al. 1981, Levy et al.2003, Schuller & Kalsbeek 2003,)

Score:0: no plaque, no bleeding upon probing1: limited amount of dental plaque2: clearly visible plaque and bleedingupon probing

•

Cooperation.

Behaviour managementproblems/dental anxiety. Dental anxietyresults in avoidance behaviour (Davey1989). Dental anxiety is related to expo-sure to restorative treatment and newlydeveloped dental caries. (Milgrom 1995,Ten Berge 2001). Repetitive dental

EYC attention areas

Age in years 1 yr 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Assessment

caries risk)

a

Preventive

attitude)

a

Cooperation)

a

Developm.l disturbances

Oral habits

Approximal caries

Fissure caries

Feeding habits

Periodontal problems

High alert Close attention Normal attention

a. Parameter for EYC.

96

exposure leads to a sense of control ofdental anxiety (Locker et al. 1996). Den-tists are well able to assess dental anxietyon a simple scale (Ten Berge et al. 2002).Score:0: age appropriate behaviour1: stress or anxiety during parts of thetreatment2: anxious. Overreaction on normaldental stimuli.

•

Caries

. Dental caries is the best knownpredictors of dental caries. (Pelkwijk etal. 1990, Roeters 1992, Vanobbergen etal 2001). Therefore children withrecently developed or filled cariouslesions (e.g. within the year) need to beput into a higher risk category.Score:0: sound, no demineralisations1: one ore two demineralisations2: recently developed or filled lesions

Each of the criteria above forms a separaterisk category that can lead to a decisiverisk assessment of the child.

• Caries risk: the highest score is decisiveApplication of the rules above leads tothe following risk categories, with risk-related preventive therapy.0: no risk:a yearly check-up interval issufficient1: some risk: simple measures can betaking during the check-up session or ina separate control session.2: risk: additional preventive measure-ments are needed to positively influ-ence the caries risk; several additionalappointments during the coming year.

If a child scores a 2 (risk) for one of thethree categories, the child is automaticallyconsidered as a child at risk for the forth-coming year, the risk interval. For that year

a higher level of preventive care is neededand paid for

(Fig 1)

.

…3 years, brushing o.k., sound teeth, notafraid: risk 0…

…4 years, brushing mediocre, 1 cavity,afraid: risk 2…

Relative frequency of the EYC

The dental risk assessment is valid till thenext EYC, after a year. Then the next riskassessment follows, resulting in a preven-tive planning for next year. From 5 years ofage, bite wing radiographs are mandatoryfor refunding of the EYC. If no (initial)lesions can be found on the first x-rays,next bite wings can be made after 2-3years. If the risk is assessed at level 2 pre-ventive measures can be planned in thefrequency the dentists considers neces-sary.

Clinical try out

The EYC was tested in a randomizedgroup of 35 Dutch dentists. The dentist intotal treated 1245 children in the period of01-01-2003 to 01-03-2003. They assessedthe caries risk for each individual child

(table 1)

.All dentists were well able to apply the riskassessment tool of the EYC adequately.The total reported risk group was 26,8%,which should be possible to reduce aftercloser instructions and guidelines. Riskassessment was related to patient’s age,dental status and preventive pattern. Thedentists did not use more time with theschedule and seemed to see the EYC as a

3 years

P

revention: 0

C

aries: 0

C

ooperation: 0 Risk: 0

4 years

P

revention: 1

C

aries: 2

C

ooperation: 1 Risk: 2


97

support in the routine check-up and oralcare of children teeth. The clinical use ofthe risk parameters is interesting.

The task force reports to the board of theNMT. A positive advice on the EYC wasgiven. The board has to further decide onthe financial consequences: develop theroutine treatments that are allowed to bedone in caries risk children. A further eval-uative study on the financial conse-quences is advised.

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experiences and their relationship to dental anxi-ety.

Com Dent Health

1996; 13: 86-92.Loveren C & Veerkamp JSJ. Kinderen met een

verhoogd cariës risico. In v. Amerongen e.a.: Kin-dertandheelkunde deel II, Bohn Stafleu, Van Log-hum, Houten 2002.

Table 1. Risk status, as judged by the individual dentist.(n=1245).

Risk level Coöperation Prevention Caries CPC

0 85.7% 53.3% 63.4% 41.4%

1 11.4% 36.0% 16.5% 31.8%

2 2.9% 10.7% 20.1% 26.8%

Total

98

Maanen H. van: Voorkomen is duurder dangenezen. P.37-43. Boom, Belvedere, Amsterdam1999. ISBN 90 5352 5491.

Milgrom P, Mancl L, King B, Weinstein P. Ori-gins of childhood dental fear.

Beh, Res. Ther

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ter Pelkwijk A, van Palenstein Helderman WH,van Dijk JWE. Caries experience in the deciduousdentition as predictor for caries in the permanentdentition

. Caries Re

1990; 24: 65-71.Powell LV. Caries prediction: A review of the

literature.


1998;26: 361-371.

Raadgevend Comité voor de Opleiding van deBeoefenaar der Tandheelkunde. Eu-rapport XV/D/8011/3/97-NL. België, Brussel, 2000.

Roeters FJM. Prediction of future caries devel-opment in preschool children. Nijmegen Univer-sity thesis 1992.

Schuller AA & Kalsbeek H. Effect of the routineprofessional application of topical fluoride oncaries treatment experience in adolescents of lowsocio-economic status in the Netherlands.

CariesRes

2003; 37: 172-177.Vaanobbergen J, Martens L, Lesaffre E, Bogaerts

K, Declerck D. The value of a baseline caries riskassessment model in the primary dentition for theprediction of caries incidence in the permanentdentition.

Caries Res

2001; 35: 442-450.Weerheijm KL, Groen HJ, Beentjes VEVM,

Poorteman JHG. Prevalence of cheese molars in11-year-old Dutch children.

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2001;68: 259-262.

99

Oral Health-Related Quality of Life (OHRQoL)Review of existing instruments and suggestions for use in oral health outcome research in Europe


1

Introduction

The term “health related QoL” has nostrict definition, but there is a consensusthat the construct is multidimensional andcaptures people’s perceptions about fac-tors that are important in their everydaylives (Slade, 2002).The oral health-related quality of life(OHRQoL) concept refers to self-reportsspecifically pertaining to oral health, andcaptures both the functional, social andpsychological impacts of oral disease (Gift& Redford 1992). Shifting the purpose ofmeasurement from disease conditions tothe perceived impacts of oral diseases, themeasures have varied from direct clini-cally based indices indicating normativeneeds to indirect measures of felt need interms of self-report indicators. The mea-sures have varied from instruments tomeasure single dimensions of oral healthto scoring systems comprising compositesocio-dental indicators or OHRQoL mea-sures. Socio-dental indicators are definedas any measure to estimate the social

impact of oral conditions (Reisine 1981) orthe extent to which dental and oral condi-tions disrupt an individual’s quality of life.The various OHRQoL indicators are tovarying extent based on a conceptualframework derived from the InternationalClassification of Impairments, Disabilitiesand Handicaps (ICIDH) developed byWHO in 1980 (Badley 1987), and thatwas subsequently amended for dentistryby Locker (Locker 1988). The ICIDHmodel consists of the following key con-cepts: impairments, functional limitations,pain, disability and handicap. It provides atheoretical basis for the empirical explora-tion of the links between various dimen-sions of health and oral health.

Clinical studies using patient-based outcomemeasures have shown that they can providenew information about the effectiveness ofdifferent treatments (Heydecke 2002), andsuch measures are now generally acceptedas the ultimate outcome of the oral healthcare system (Inglehart & Bagramian, 2002).The concept of OHRQoL has been con-firmed and validated cross-culturally by the

1. University of Bergen, Norway

100

ICSII study (

Comparing Oral Health CareSystems, a second international collabora-tive study

) in the context of a multinationalinvestigation of oral health determinantsand outcomes (Chen et al. 1997). However,the application of an increasing number ofvarious socio-dental indicators makes sur-veillance and comparison of perceived oralhealth difficult, within and across differentpopulations in Europe. If possible, a limitedset of instruments should be recommendedfor use, and generally they should be effi-cient, easy to complete and easy to handle.The concept of oral quality of life is, how-ever, imbued with values and thus variesaccording to social, cultural and politicalcontext, and therefore the efforts towardsstandardization of instruments are war-ranted in terms of agreeing upon instru-ments that can be recommended for use fordifferent purposes (e.g. in population sur-veys, intervention studies).A first step in selecting an appropriateOHRQoL instrument is to specify the exactpurpose or aim in using such a measure interms of being descriptive, discriminativeor evaluative. The second step is to identifya measure whose properties conform to theintended study aims. In some cases therewill be need for generic instruments and inother cases for more condition specificmeasurements. Instruments used in surveyresearch will need specific qualities, whilethe use of questionnaires in longitudinaldesigns intended to measure change inOHRQoL on population- or on individuallevels represents greater methodologicalchallenges (Slade, 2002). It cannot beassumed that a measure proved to be reli-able and valid in cross-sectional popula-tion studies will be suitable for the purposeof detecting meaningful clinical changes ina longitudinal intervention.

The latter purpose needs properties suchas responsiveness and interpretability(Guyatt, Walter et al. 1987). To date, theresponsiveness of many OHRQoL instru-ments has not been established, althoughthere is an increasing tendency to useOHRQoL measures as outcomes in clini-cal trials and evaluation studies. Longitu-dinal studies assessing changes inOHRQoL as a time effect or in response totreatment and preventive procedures areneeded (Chavers et al. 2003), to explorethose qualities (Allen 2003).For oral health related quality of life mea-surements, many different instrumentsalready exist

(Table 1)

. While most of themeasures appear to be theory based andwell tested for psychometric properties,only a few of them have been widely usedby others in addition to the ones responsi-ble for their development. There is needfor an assessment aimed at presenting apriority of recommended instruments tobe used for different purposes, and thenplan for future research for further evalua-tions. The first step in this process shouldbe to explore and evaluate existing instru-ments.

Aims

The present evaluation had the followingaims: 1) Based on the existing literature, toevaluate currently used oral quality of lifeinstruments in terms of the extent to whichvarious psychometric properties havebeen established; 2). To include a few ofthe existing instruments in priority groupsfor measurement of the quality of life com-ponent of oral health in Europe; and 3). Torecommend new research directions tofurther increase their qualities for futureoral health outcome research.

Oral Health-Related Quality of Life (OHRQoL)

101

Table 1. OHRQoL instruments used in research during the period from 1985-2004.

Instrument Abbrev# of

ItemsOriginalreference

Long/ Interv.

Studies used

Social Impact of Dental Disease

SIDD 14. Cushing et al. 1986

Cushing et al. 1986

Oral Health and the Sickness Impact Profile

-SIP 73 Reisine et al. 1989

Reisine et al. 1989

Geriatric (General) Oral Health Assessment Index

GOHAI 12 Atchison & Dolan 1990 +

Atchison & Dolan 1990; Kressin et al. 1997Dolan 1997, 1998; Jones et al. 2003Locker et al. 2001, 2002;Wong et al. 2002

OHRQoL The DELTA

6 Kressin et al. 1996Jones et al. 2003

Kressin et al. 1996Jones et al. 2003

Rand Dental Health Index

3 Dolan et al. 1991

Dolan et al. 1991

Dental Impact Profile

DIP 25 Strauss & Hunt 1993

Strauss & Hunt 1993

Psychosocial Impact Score

42 Locker & Miller 1994

Locker & Miller 1994

Oral Health Impact Profile

OHIP-49

49 Slade & Spencer 1994

+ Jones et al. 2003, Allen & McMillan 2003Locker & Allen 2002Allen & Locker 2002, Wong et al. 2002Awad et al. 2000; 2003a, 2003bBroder et al. 2000Allen et al. 1999Allison et al. 1999, Slade 1998, Locker 1995


OHIP-14

14 Slade 1997 +++++ Llewellyn & Warnakulasuriya 2003McGrath et al. 2003b, 2003c, 2003dRobinson et al. 2001,2003Hegarty et al. 2002Allen & Locker 2002Locker et al. 2001, 2002b, 2004Locker & Allen 2002Awad et al. 2003aEkanayake & Perera 2003Perera & Ekanayake 2003

Oral Health Impact Profile(OHIP-EDENT)

OHIP-20

20 Allen & Locker 2002

++ Awad et al. 2003aHeydecke et al. 2003Allen & Locker 2002

102

German version of the Oral Health Impact Profile (OHIP 49)

OHIP-G 53 John et al. 2002

John et al. 2002John et al. 2003

Oral Health-Related Quality of Life Measure

OHQOL

3 Kressin et al. 1996

Kressin et al. 1996

Dental Impact on Daily Living

DIDL 36 Leao & Sheiham 1996

Leao & Sheiham 1996

Oral Impacts on Daily Performances

OIDP 9(8) Adulyanon & Sheiham 1997

Astrom & Okullo 2003Robinson et al. 2001, 2003Masalu & Astrom 2002, 2003Cortes et al. 2002Tsakos et al. 2001Sheiham et al. 2001Melas et al. 2001

The Oral Health Quality of Life Inventory

OH-QoL

56 Cornell et al. 1997

Cornell et al. 1997

The Oral Health Quality of Life Inventory

OH-QoL

15 Cornell et al. 1997

Cornell et al. 1997

Subjective Oral Health Status Indicators

42 Newman 1999

Newman 1999

The Oral Health-Related Quality of Life Instrumentfor Dental Hygiene

Gadbury-Amyot et al. 1999

Gadbury-Amyot et al. 1999

Orthognatic Quality of LifeQuestionnaire

OQoLQ 22 Cunningham et al. 2000

+ Cunningham et al. 2000

UK Oral Health-Related Quality of Life Measure

OHQoL-UK

16 McGrath and Bedi 2001

++++ McGrath et al. 2003 a, 2003b, 2003c, 2003dDini et al. 2003McGrath & Bedi 2001b, 2002Hegarty et al. 2002




Long/ Interv.

Studies used


103

Review

Table 1

shows a summary of availableinstruments that was used as the basis forfurther exploration of qualities. The over-view of available instruments is based ona PubMed search covering the period1985-2004.Studies have shown that both additive andweighting standardized methods performwell for QoL instruments (Robinson al.2003), but also that weighting not neces-sarily improves the psychometric proper-ties (McGrath & Bedi, 2002). This method-ological aspect has not been considered inthis evaluation.We believe that it might be difficult toidentify one instrument that fulfils allrequirements – and it seems reasonable torecommend a set of various indicators thatcan be used for different purposes.Based on the review

(Table 1)

, the instru-ments are therefore allocated to prioritygroups as agreed upon in the EuropeanOral Health Indicators Project meeting(Lyon, September 2003):

Group 1:

Core indicators

. In this group wehave decided to include generic instru-ments that have been widely tested. Theyhave been shown to have the best qualitiesbased on the research published so far, andare easy to use in population studies.Group 2:

Expanded level of instruments

.In this group are included generic instru-ments that may represent supplements tothe instruments in Group 1 as well as morecondition or age specific instruments.Group 3.

Optional level of instruments

.This group includes instruments that so farhave been evaluated to a lesser extent.They may, however, by further testingshow good qualities.The selection of instruments in prioritygroups is shown in

Table 2

.Our allocation of instruments to Group 1and 2 is based on the following evalua-tion:


The original OHIP-instrument (OHIP-49)(49 items) was developed by Slade and

Child Oral Health Quality of Life Instrument

COHQOL

Jokovic et al. 2003Tapsoba et al. 2000

Child Perceptions Questionnaire

CPQ

11-14

36 Jokovic et al. 2002

Jokovic et al. 2002

Parental-Caregiver Perceptions Questionnaire

P-CPQ 31 Jokovic et al. 2003

Jokovic et al. 2003

Family Impact Scale

14 Locker et al. 2002

Locker et al. 2002




Long/ Interv.

Studies used

104

Spencer (Slade & Spencer, 1994) based ona conceptual framework of oral diseaseand its functional and psychological con-sequences. The instrument is divided intoseven subscales (functional limitations,pain, psychological discomfort, physicaldisability, psychological disability, socialdisability and disadvantage) (Slade &Spencer 1994, Jones 1998). This instru-ment is widely used and tested, also inlongitudinal studies to evaluate change inquality of life among elderly people (Slade1998) and in patients with implant-retained dentures (Allen et al. 2001, Awadet al. 2003).Shortened versions of the original scalehave been developed, providing some-what compromised instruments in terms ofcontent validity.

The OHIP-14 version is ashortened version of the original OHIP-49-item scale (Slade and Spencer, 1994). It iseasy to use, and has been tested for psy-chometric qualities in several studies indifferent populations

(Table 1).

The OHIP-14 has been shown to have measurementproperties comparable with the full 49-item version (Allen & Locker 2002).The short version instrument has also beenused in clinical trials (Awad et al. 2000)and shown to be sensitive to clinicaleffects of treatment (McGrath et al. 2003).The fully developed instrument (49 items)has, however, been shown to be betterwith respect to responsiveness than theshorter versions (Locker & Allen, 2002).We are suggesting that both the OralHealth Impact Profile (OHIP-49) and theshortened version Oral Health Impact Pro-file (OHIP-14) could be included in thecore group of instruments. They have bothbeen tested extensively and shown to havegood construct, discriminative and longi-tudinal validity.

The Oral Health Impact Profile (OHIP-EDENT) is also a modified shortened (20items) version of the original 49-itemscale. This modified version has beenshown to have measurement propertiescomparable with the full 49-item version(Allen & Locker, 2002) and

may be moreappropriate for use in edentulous patientsthan the short version OHIP-14. We sug-gest that the (OHIP-EDENT)

could beincluded as one of the Group 2 instru-ments

(Table 2).

UK Oral Health-Related Quality of Life Measure (OHQoL-UK)

This instrument is also widely tested andused in different studies, both cross-sec-tional and longitudinal design. The instru-ment is easy to use, has shown good psy-chometric qualities and also found to besensitive to clinical effects of treatment(McGrath et al. 2003d). We are suggestingthat the instrument could be included inthe core group.

Oral Impacts on Daily Performances (OIDP)

This instrument has 8 (9) items comprisingone domain (the ultimate impacts or phys-ical, psychological and social aspects ofperformance of daily living) and satisfac-tory psychometric qualities in terms ofreliability (internal consistency and test-retest) cross-sectional construct and dis-criminative validity have been establishedin different cultural contexts (Adulyanon &Sheiham 1997, Melas et al. 2001, Tsakoset al. 2001, Masalu & Astrom 2002,Astrom & Okullo 2003, Masalu & Astrom2003, Robinson et al. 2003).


105

Table 2. Proposed instrument in priority groups.

CORE INDICATORS

Instrument Abbreviation Main domains covered Recommended use


OHIP-49 7 domains: functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap

InterventionEvaluation researchCross-sectional population studies

Oral Health Impact ProfileOHIP-14

OHIP-14 7 domains: Functional limitationPhysical painPsychological discomfort Physical disabilityPsychological disabilitySocial disabilityHandicap

InterventionEvaluation researchCross-sectional population study

UK Oral Health-Related Quality of Life Measure

OHQoL-UK 16 key areas: comfort, breath odour, general health, eating, appearance, speech, relax and sleep, smiling/laughing, confidence, mood, carefree manner, personality, work, social life, finances, romantic relations

InterventionCross-sectional population research


OIDP 1 domain: disability in terms of physical, psychological and social aspects of daily performances

Cross-sectional population study


OIDP 1 domain: disability in terms of physical, psychological and social aspects of daily performances


Oral Health Impact ProfileOHIP-14

OHIP-14 7 domains: Functional limitationPhysical painPsychological discomfort Physical disabilityPsychological disabilitySocial disabilityHandicap

InterventionEvaluation researchCross-sectional population study

EXPANDED LEVEL OF INSTRUMENTS

Geriatric (General) Oral Health Assessment Index

GOHAI Physical functionPsychosocial functionPain and discomfort


Child Oral Health Quality of Life Instrument(including subscales, see text)

COHQOL Oral symptomsFunctional limitationsEmotional well-beingSocial well-being

Cross-sectional population studies

Orthognatic Quality of Life Questionnaire

OQoLQ Social aspects of deformityFacial aestheticsFunctionAwareness of facial deformity

Intervention

Oral Health Impact Profile(OHIP-EDENT)

OHIP-20 Functional limitationPhysical painPsychological discomfort Physical disabilityPsychological disability


OPTIONAL LEVEL OF INSTRUMENTS

The remaining instruments (not allocated to groups 1 or 2) may by further testing show good qualities, but we find no basis for any kind of priority assignment in this group.

106

The instrument consists of eight items cover-ing physical, psychological and social per-formances (eating and enjoying food,speaking and pronouncing clearly, cleaningteeth, sleeping and relaxing, smiling, laugh-ing and showing teeth without embarrass-ment, maintaining usual emotional statewithout being irritable, carrying out majorwork or social role, and enjoying contactwith people) (Adulyanon & Sheiham, 1997).The scale assesses the frequency and theseverity of the impact. The scores areweighted for each item and then summedto a total OIDP score. It is easy to apply inlarge population studies being short and inevaluating the ultimate outcomes of oraldiseases. It is also easier to assess psycho-metric properties of behaviours comparedto concepts like feelings, evaluations etc(measures reflect underlying phenomena).Recent research indicates that the instru-ment is responsive to change (Locker et al.2004), and we find this instrument sopromising that it is proposed as one of thecore group instruments.

Geriatric (General) Oral Health Assessment Index (GOHAI)

This instrument was developed and testedby

Atchison and Dolan (1990) for evaluat-ing functional status, pain and discomfort,worry, ability to chew and swallow, andsocial functioning. The initial testingshowed satisfactory psychometric proper-ties, but correlated only weekly with someof the oral status indexes. The scale hasbeen widely used, and also tested longitu-dinally for changes in perceived oralhealth among elderly

(Dolan et al. 1998,Locker 1998). The instrument is age spe-cific and could be one of the Group 2instruments

(Table 2)

.

Child oral health related quality of life questionnaires

The Child

Oral Health Quality of LifeQuestionnaire (COHQOL) has beendesigned to assess the impact of oral andorofacial conditions on the quality of life ofchildren and their families (Jokovic et al.2002). The Family

Impact Scale is onecomponent of the COHQOL and consistsof Child Perception Questionnaires (CPQ

11-14

and CPQ

6-10

) and the Parental-Care-giver Perceptions Questionnaire (P-CPQ).Dependent on the age of the children,child oral health-related quality of life hasto be measured either based on the care-giver’s or the child’s own views. Studieshave indicated that both the views of thecaregiver (measured by PPQ) and of thechild itself (CPQ

11-14

) should be includedto fully represent child oral health-relatedquality of life (Jokovic et al. 2003). Thischild oral health related quality of lifequestionnaires could be included in theexpanded level of instruments group as asupplement to the core group instruments.

Orthognatic Quality of Life Questionnaire

The OQoLQ is a condition-specific instru-ment for patients with severe dento-facialdeformities requiring orthognathic treat-ment (Cunningham et al. 2000). We sug-gest that such condition specific instru-ments should be included in the expandedlevel of instruments group.

Directions for future research

No single instrument can be regarded as astandard, comprehensive instrument formeasurement of OHRQoL. There willalways be a need for generic and more dis-


107

eases-/condition specific instruments. Char-acteristics of a good instrument may differfor group comparisons for public healthpurposes compared to measurement ofwithin-subject changes. The present evalu-ation clearly shows that there is need formore research to be able to recommend afinal list of core instruments that should beused in different types of research exploringOHRQoL aspects. A lot of methodologicalissues are still not finally evaluated for theassessment of quality of life aspects inEurope. Future studies should be designedto test the instruments’ discriminating qual-ities for different kinds of interventions indifferent age groups and European popula-tions. The present list should be regarded aspreliminary and as a basis for the selectionof instruments for future studies.

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McGrath C & Bedi R. Population based normingof the UK oral health related quality of life mea-sure (OHQoL-UK). Br Dent J 2002; 193: 521-4.

McGrath C, Alkhatib MN, Al-Munif M, Bedi R,Zaki AS. Translation and validation of an Arabicversion of the UK oral health related quality of lifemeasure (OHQoL-UK) in Syria, Egypt and SaudiArabia. Community Dent Health 2003a; 20: 241-5.

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McGrath C, Comfort MB, Lo EC, Luo Y.Changes in life quality following third molar sur-gery--the immediate postoperative period. BrDent J 2003c; 194: 265-8.

McGrath C, Hegarty AM, Hodgson TA, PorterSR. Patient-centred outcome measures for oralmucosal disease are sensitive to treatment. IntJ Oral Maxillofac Surg 2003d; 32: 334-6.

Melas F, Marcenes W, Wright PS. Oral healthimpact on daily performance in patients withimplant-stabilized overdentures and patients withconventional complete dentures. Int J Oral Maxil-lofac Implants 2001; 16: 700-12.

Newman L. (1999). Medical Outcomes and Guide-lines Sourcebook. New York, Faulkner and Gray.

Perera I & Ekanayake L. Prevalence of oralimpacts in a Sinhala-speaking older population inurban Sri Lanka. Community Dent Health; 2003;20: 236-40.

Reisine ST. (1981). Theoretical considerationsin formulating sociodental indicators. Soc SciMed; 745-50.

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110

Robinson PG, Gibson B, Khan FA, BirnbaumW. A comparison of OHIP 14 and OIDP as inter-views and questionnaires. Community DentHealth 2001; 18: 144-9.

Robinson PG, Gibson B, Khan FA, BirnbaumW. Validity of two oral health-related quality oflife measures. Community Dent Oral Epidemiol2003; 31: 90-9.

Sheiham A, Steele JG, Marcenes W, Tsakos G,Finch S, Walls AW. Prevalence of impacts of den-tal and oral disorders and their effects on eatingamong older people; a national survey in GreatBritain. Community Dent Oral Epidemiol 2001;29: 195-203.

Slade GD. Derivation and validation of a short-form oral health impact profile. Community DentOral Epidemiol 1997; 25: 284-90.

Slade GD. Assessing change in quality of lifeusing the Oral Health Impact Profile. CommunityDent Oral Epidemiol 1998; 26: 52-61.

Slade GD & Spencer AJ. Development andevaluation of the Oral Health Impact Profile.Community Dent Health 1994; 11: 3-11.

Slade G. (2002). Assessment of Oral Health-Related Quality of Life. Oral Health-RelatedQuality of Life. M. R. Inglehart and R. A.Bagramian, Quintessence Publishing Co.Inc.

Strauss RP & Hunt RJ. Understanding the valueof teeth to older adults: influences on the qualityof life. J Am Dent Assoc 1993; 124: 105-10.

Tapsoba H, Deschamps JP, Leclercq MH. Fac-tor analytic study of two questionnaires measur-ing oral health-related quality of life among chil-dren and adults in New Zealand, Germany andPoland. Qual Life Res 2000; 9: 559-69.

Tsakos G, Marcenes W, Sheiham A. Evaluationof a modified version of the index of Oral Impactson Daily Performances (OIDP) in elderly popula-tions in two European countries. Gerodontology2001; 18: 121-30.

Wong MC, Liu JK, Lo EC. Translation and vali-dation of the Chinese version of GOHAI. J PublicHealth Dent; 2002; 62: 78-83.

Wong MC, Lo EC, McMillan AS. Validation of aChinese version of the Oral Health Impact Profile(OHIP). Community Dent Oral Epidemiol 2002;30: 423-30.

111

Oral Health Indicators: National views

National oral health information system, some Danish experiences

Lisa Boge Christensen

Concise review on the provision of oral health care, oral health status and oralhealth indicators in the Belgian population.


European Global Oral Health Project - Critical analysis of oral health determi-nants

Carina Källestål

Information needed for regulating oral health services: a Finnish perspective

Anne Nordblad and Annamari Nihtilä

113


Lisa Bøge Christensen

1

Introduction

In 1972 a recording system was launchedwith the purpose of processing large quan-tities of dental health information obtainedfrom the total population of school chil-dren in Denmark. The data collection sys-tem incorporates two important functions.It serves as a supplement to the patient’sindividual dental record at the local level,and also it serves as input for further statis-tical data analysis at regional and nationallevel

Historical background

The background for developing such arecording system was the Act on ChildDental Health passed by the Danish Par-liament in 1971. According to this lawdental care shall be offered to all school-children in the country regardless of theirresidential area. According to the law allmunicipalities were made responsible ofestablishing dental clinics and employingdentists and auxiliaries in sufficient num-

bers to provide comprehensive dentalcare, preventive and curative services forall children 7-15 years of age.The service was extended to include 0-18year-olds in 1986. Before 1971 dentalcare of Danish school children was basedon the initiative and interest of individualmunicipalities and there were no overallplanning or national coordination. TheAct of 1971 imposed the National Boardof Health the responsibility of developinga system for recording and analysis of den-tal health data in order to provide informa-tion for planning, monitoring, and evalua-tion at regional and national levels.Considerations were made on collectingepidemiological data from representativesamples of children in selected municipal-ities receiving public dental care. How-ever, it was found that such system wouldentail several disadvantages.Thus, the recorded data could not be usedfor planning and evaluation of programmeat the municipal level, and the data couldnot be used for treatment planning of theindividual patients. Collecting data by

1. Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.

114

sampling would imply that some staffwould have an extra workload to obtainsummary statistics of little relevance to thelocal clinic or local municipality. Suchsystem might have a negative impact onthe interest of staff involved, and it mightaffect the use and the quality of the datarecording negatively.Consequently, it was decided to base thedata recording system on information fromall children served (i.e. the total populationof children) and thereby to stimulate pro-viders of dental care to use the data andsummary statistics for local purposes.Recordings of dental health status aremade on duplicate forms partly to serve asa supplement to the patient’s individualtreatment record and partly as input for fur-ther data analysis electronically. Such dualfunction became possible with the devel-opment of computer input devices forOptical Character Reading (OCR). Hand-written symbols were scanned, identifiedand coded for direct data entry. By meansof such system conventional punch cards(normally used at that time) were avoided.Since the National Recording System forthe Child Dental Health Services waslaunched in 1972 it has been reviewed andupdated. Due to the significant decline incaries prevalence registration is compul-

sory by now for selected age groups only(5, 7, 12 and 15 years of age). Since 1994electronic registration has been availableand to-day 40% of the municipalities trans-fer data via the on-line system.The system has been in function for morethan 30 years, it has been revised andsome changes have been made. By nowthe system is not only a tool for organiza-tion development and goals for healthpolycy but also a system for monitoringthe health situation.

The recording system and oral health indicators

The registration of data is based upon arecord form shown in

figure 1

. To enablethe scanner to identify the input all dataare entered as numbers written in a dis-tinct way as indicated in the top-line of therecord form.Record form showing the findings at theexamination of a girl born on March 26th,1975. Municipality code 219; school code003; school class not indicated; examina-tion date 28th October, 1988: 8+, 2+(congenital absence), +7, +8, 8-, and -8have not erupted. 05+, 03+, +05, 05-, and-05 have not been replaced by their per-manent successors.

Figure 1.


115

For DMF code numbers see text

(Table 1)

.Gingivitis scoring upper jaw indicateshealthy gingiva or only slight gingivitis, 2+ ismissing, and recording can not be done onthis specific tooth. Gingivitis scoring lowerjaw indicates bleeding on probing. Pocketsare not recorded (the child is only 13 years).Recording of rotation +2, deep bite, distalmolar occlusion right site, mandibularmidline displacement, crowding mandib-ular incisor segment.The form includes boxes for recording identi-fication of the child and for registration of dis-ease conditions. Personal identification num-ber includes ten digits (all Danish citizenshave a unique identification number) contain-ing information on date of birth and sex. Also,codes for municipality, school, and class areincluded in the form. Boxes are available forfurther individual classification such as socialgroup, ethnic group etc. The largest part of the

record form is used for registration of cariesstatus. The form is based on the Haderup den-tal notation system (8+ to +8 for the maxillaryand 8- to –8 for the mandibular teeth). Anerupted primary tooth is indicated by 0 and apermanent tooth is indicated by 1

(Fig.1)

.For each tooth a set of coding boxes are pro-vided to enter observations relevant to thetooth surface level: Occlusal, mesial, facial(buccal/labial), distal, and oral (lingual/pala-tal). For canines and the incisors only fourspaces are provided, the incisal edge notbeing counted as a separate occlusal sur-face. All sound tooth surfaces are left blank.For registration of caries and other condi-tions certain scores are specified

(Table 1)

.Criteria for gingivitis and periodontitis areshown in

Tables 2 and 3

. Twelve index-teeth per person are examined. In case theindex tooth is not present the box ismarked with X.

Table 1. Conditions, code, and diagnostics criteria for registration of caries, etc.

Condition Code Diagnostic criteria

Initial caries 0 The enamel has surface is rough with opacity, no cavity

Manifest caries 1 The enamel has surface is rough with opacity. Decay with cavity

Secondary caries or lost/defective filling 2 Manifest caries on a surface already filled due to caries

Chronic caries lesion (registration optional)

9 The enamel surface is hard, smooth, shiny, has whitish or brownish discoloration

Filling 4 Restorations made due to caries (fillings, inlays, crowns)

Trauma 3 Injuries due to mechanical trauma (treated or untreated) excluding infractions and enamel fractures.

Endodontic treatment due to caries 5 Pulp capping, pulpotomy or pulpectomy

Missing (due to caries) 6

Missing (other reasons) 7 Missing due to trauma or orthodontic treatment

Fissure sealant (registration optional) 8

Table 2. Registration of gingivitis (optional).


Gingivitis 1 Bleeding after probing

Indicator tooth is missing X

116

Criteria for compulsory registration of den-titional anomalies, occlusal anomaliesand space anomalies are shown in

Table 4

. The purpose of registration ofthose five types of malocclusion is toenable the authorities monitor the occur-

rence of such conditions, which normallyentail orthodontic treatment and conse-quently high costs. Other types of devia-tions are optional and comprise verticalanterior open bite, diastema, antero-pos-terior molar relation, spacing etc.

Statistical output

Once a year health statistics are produced atregional and national levels and forwardedto the municipal oral health planners andproviders of dental care. Sets of standardtables are produced for each municipality,each country, and for the whole country. Allmunicipalities are provided a set of standardtables

(Table 6)

. Additional tables can beobtained if required. Standard tables

describe the prevalence of caries in the pri-mary dentition

(Table 1-3)

and in the perma-nent dentition

(Table 4-6)

. The tables presentthe distribution of caries quantitatively bythe components of def-s and DMF-S, andqualitatively by caries distributions accord-ing to severity zones

(Table 5)

. The descrip-tive statistics include parameters such asmeans and standard deviations. Medians arealso shown and 1st and 3rd quartiles for def-s and DMF-S indices.

Table 3. Registration of marginal periodontitis (compulsory for 12 and 15 year old children).


Periodontitis 1 Loss of attachment observed by probing

Indicator tooth is missing X

Table 4. Registration of traits of malocclusion, compulsory for 12 and 15 year old children.

Condition Diagnostic criteria

Anterior maxillary overjet Overjet 6 mm or more

Deep bite Vertical distance

≥

5 mm between incisal edges in upper and lower jaw

Crowding 2 mm or more in total either in upper or lower jaw

Hypodontia Aplasia 1-5 permanent teeth

Oligodontia Aplasia more than 5 permanent teeth

Table 5. Caries severity zones of individuals.

Condition Diagnostic criteria

Zone 4 Caries in incisors and smooth surfaces

Zone 3 Approximal caries in canines, premolars and molars

Zone 2 Caries in pits and fissures

Zone 1 Caries free


117

Conclusion

The National Recording System for theChild Dental Health Services has been infunction for more than 30 years. The sys-tem has currently been updated on basisof reviews and evaluations. This epidemi-ological tool functions as an integratedpart of the Municipal Dental Health Ser-vice in Denmark. A number of reportshave been published by the authorities onbasis of the aggregated data. At the locallevel the system has been applied forcohort studies and evaluation of local oralhealth programmes. In addition, therecording system has been applied in asubstantial number of epidemiologicalsurveys in countries outside Denmark.

References

Friis-Hasché E. Child oral health care in Den-mark. Copenhagen University Press. Faculty ofHealth Science, School of Dentistry Copenhagen1994.

Helm S. Recording system for the Danish ChildDental Health Services.

Community Dent OralEpidemiol

1973; 1: 3-8.Helm S & Helm T. Caries among Danish

schoolchildren in birth-cohorts 1950-78.


1990; 18: 66-69Petersen PE. Effectiveness of oral health care--

some Danish experiences.

Proceedings of theFinnish Dental Society

, 1992; 88: 13-22.Poulsen S. Dental caries in Danish children and

adolescents 1988-94.

Community Dent Oral Epi-demiol

1996, 24: 282-285.National Health Service. Report on oral health

care among children and adolescents. Copen-hagen 1999.

Table 6. List of standard tables produced once a year and provided to the users of the system.

Primary dentition

1. Mean number of surfaces present, decayed, filled or missing due to caries per person by age

2 Percentages of persons distributed by def-s and age

3 Percentages of persons distributed by caries severity zones and age

Permanent dentition

4 Mean number of surfaces present, decayed, filled or missing due to caries per person by age

5 Percentages of persons distributed by DMF-S and age

6 Percentages of persons distributed by caries severity zones and age

7 Occurrence of initial caries (code 0) in permanent teeth

8 Distribution of persons by number of permanent teeth with loss of attachment, injuries after mechanical trauma and teeth with endodontic treatment due to caries

9 Occurrence of malocclusions etc.

118

Concise review on the provision of oral health care, oral health status and oral health indicators in the Belgian population


1

Introduction

Belgium is a Federal state with a popula-tion of 10.309.725 million inhabitants(National Institute of Statistics, 2002).There are three regional authorities ofFlanders, Wallonia and Brussels and threelanguage communities, i.e. Dutch-,French-, and German-speakers, represent-ing 57%, 42% and 1% of the population,respectively (Carvalho et al. 2001b). Theoral health care system is unique for thewhole country and it is under the respon-sibility of the Ministry of Health and SocialAffairs.The organisation of the oral health systemcan be categorised as the Bismarckianinspired model, which is rooted in theprinciple of the National Health Insurance(Widström & Kenneth 1999). In order tobe covered by the National Health Insur-ance one may pay a contribution. Thiscontribution is obligatory for those whowork in Belgium, except for employees ofthe European Commission, European Par-liament, United Nations Organisations,

and Diplomatic Representations, that mayhave a private insurance. About 90% ofthe Belgian population benefited from theNational Health Insurance (NationalHealth Institute, 2003).The contributions are paid to the NationalHealth Insurance that refunds MutualInsurance Associations. The Mutual Insur-ance Associations negotiate fees directlywith dental associations and syndicates,every second year. The fees for selecteddental procedures have to be agreed by60% of the dentists, otherwise the feesproposal collapses (Widström & Kenneth1999). The dentists who do not agree withthe fees proposal have to inform it to theNational Health Insurance by registeredletter and may then establish their ownfees.The Mutual Insurance Associations reim-burse their contributors based on the feesestablished by the agreement and contrib-utor’s characteristics. Widows, disable,retired and orphan contributors are fullyreimbursed while others get a reimburse-ment from 50-80%. The reimbursement is

1. School of Dentistry, Catholic University of Louvain, Brussels, Belgium.

Concise review on the provision of oral health care, oral health status and oral health indicators

119

made on fee-per-service basis for selectedtreatments. Private insurances companiesmay either be responsible for the totality ofthe reimbursement of its contributors oroffer a complementary reimbursement tothose who already benefit from theNational health Insurance.The first part of this review deals with theprovision of oral health care in Belgium.The second part describes oral health sta-tus in Belgian population. Finally, oralhealth indicators for the Belgians are dis-cussed.

Provision of Oral Health Care in Belgium

In Belgium the delivery of oral health careis essentially private for citizens of allages. There are no collective preventiveprogrammes for children and adolescents.The water supply is not artificially fluori-dated and most of the municipalities havevery low levels of fluoride in drinkingwater, < 0.3 ppm F/l (Carvalho 1998).However, fluoridated

toothpaste is preva-lent on the market and one may find low-, conventional- and concentrated fluori-dated toothpaste. Recent survey showedthat 95% of 12-yr-olds used regularly flu-oridated toothpaste and 91% of the chil-dren brushed their teeth with fluoridatedtoothpaste once or twice per day (Car-valho et al. 2001b).On the other hand, all children under theage of 18 are enrolled in the SchoolHealth Care Service, which has beenoperating in the country for more than 40years. This service, which depends onpublic subsidies, employs general medicalpractitioners who are responsible forcounselling parents, children and schoolstaff on topics like body hygiene, balanceddiet, maintenance of sound teeth, weight

control, and physical activity. These prac-titioners carry out medical check-ups inschoolchildren in their 1

st

and 3

rd

gradesof primary school and in their 2

nd

and 6

th

grades of secondary school. The medicalcheck-ups include dental examination fol-lowed by a report on treatment needs,which are sent to the parents by letter.According to Belgian law any non-opera-tive or operative dental treatment must becarried out by private practitioners or uni-versity clinics.

The ratio dentist/popula-tion is 1 dentist per 1200 inhabitants(National Health Insurance, 2002).Within the framework of the agreement onfees between the Mutual Insurance Asso-ciations and Belgian dentists the followingtreatments are currently offered: 1) twoannual oral examinations to children andadolescents and one annual examinationto individuals 18-50-yr-old, 2) dental seal-ants and orthodontics for children up to 14years old, 3) scaling once a year for indi-viduals older than 18 years and for dis-abled people, and 4) dental restorations,endodontics, removable prosthodonticsand some types of surgery for all.

Oral health status in Belgian population in the 90s and 00s

In Belgium, there is a lack of epidemiolog-ical studies on oral health in sub-popula-tions, which are representative for thewhole country. This is true for the entirepopulation: children, adolescents, youngadults and adults. Epidemiological surveyscarried out in the individual regions ofWallonia, Brussels and Flanders give ageneral idea about dental health in thecountry (Van Nieuwenhuysen et al. 1992,Declerck & Goffin 1992, Lambert et al.1997, Carvalho et al. 1998, Carvalho et al.

120

1998, Van Nieuwenhuysen & Carvalho2000, Carvalho et al. 2001a, Vanobber-gen et al. 2001a, 2001c, Bercy et al. 2002,Declerck et al. 2002), but only few studiesdocument changes in dental caries andoral health habits in Belgian children, ado-lescents and young adults over a period oftime (Van Nieuwenhuysen et al. 1998,Carvalho et al. 2001b, Van Nieuwenhuy-sen et al. 2002, Carvalho et al. 2003).

Children

–

Studies on caries prevalence inthe primary dentition of Belgian 5-, 6 and7-yr-olds documented that the percentageof caries-free children were 59% (Car-valho et al. 1998), 48% (Carvalho et al.2003) and 44% (Vanobberegen et al.2001, Vanobberegen et al. 2001, Vanob-beregen et al. 2001, Declerck et al. 2002),respectively. The mean deft scores in thesechildren were 1.6 (Carvalho et al. 1998),2.4 (Carvalho et al. 2003) and 2.2 (Vanob-beregen et al. 2001a, 2001b, 2001c,Declerck et al. 2002) and the defs scores,registered only in two studies, were 3.7(Carvalho et al. 1998) and 5.1 (Carvalho etal. 2003). In the permanent dentition ofBelgian 12-yr-olds, prevalence studiesshowed that the percentage of caries-freeranged from 25% in the early 90s(Declerck & Goffin 1992) to 50% in thelate 90s (Carvalho et al. 2001b, Van Nieu-wenhuysen et al. 2002) simultaneouslywith DMFT scores of 2.7 and 1.6, in thatorder. Data concerning DMFS scores wereonly registered in the later 90s with amean value of 2.5 (Carvalho et al. 2001b,Van Nieuwenhuysen et al. 2002).Cross-sectional investigations on changesin caries and oral health habits in Belgianchildren (Carvalho et al. 2003) and ado-lescents (Carvalho et al. 2001b, Van Nieu-

wenhuysen et al. 2002) during the last twodecades showed the following: 1) a signif-icant increase in the percentage of caries-free children in the primary dentition from32% to 48% and in the permanent denti-tion from 4% to 50%, 2) a 40% cariesreduction in deft scores and 78% in DMFTscores, 3) substantial improvement inhome-based oral health care and dentalappointments on regular basis (Carvalhoet al. 2001a, 2001b, Van Nieuwenhuysenet al. 2002).

Young adults

–

a cross-sectional study car-ried out in 1989, 1994 (Van Nieuwenhuy-sen et al. 1998)

and 1999

1

in samples ofdental students, indicated a tendency toimprovement. The percentage of caries-free young adults changed from 2.0% to5.0% and DMFT scores decreased from11.3 to 7.4.

Adults

–

an epidemiological study in Bel-gian 35-44 years, 45-55 years and > 55years reported DMFT scores of 15.4, 15.6and 16.4, correspondingly (Lambert et al.1997).

Oral health indicators for the Belgian population

Within the limits of the published investi-gations on oral health indicators in theBelgian population, one may identify twomain groups of studies. Firstly, those con-cerning oral health indicators to preva-lence studies (D’Hoore & Van Nieuwen-huysen 1991, Declerck & Goffin 1992,Gizani et al. 1999, Vanobbergen et al.2001a, 2001b, 2001c, Declerck et al.2002) and secondly of oral health indica-tors to cross-sectional studies over aperiod of time (Carvalho et al. 2001a;

1. Personnel communication.

Concise review on the provision of oral health care, oral health status and oral health indicators

121

2001b, Van Nieuwenhuysen et al. 2002,Carvalho et al. 2003).

Children

–

in

caries prevalence studies inchildren aged 7, starting bushing teethwith a fluoridated toothpaste at an earlyage, toothbrushing 1-2 times per day, flu-oride supplements, geographic area of res-idence and high socio-economic statuswere considered as good oral health indi-cators (Declerck & Goffin 1992, Gizani etal. 1999, D’Hoore & Van Nieuwenhuysen1991, Vanobbergen et al. 2001a, 2001b,2001c).Moreover, the prevalence of healthy gingi-vae in 12-yr-olds was linked to tooth-brushing 1-2 times per day and to someextent to the use of electrical toothbrush(Carvalho et al. 2001a).In cross-sectional studies, the oral healthindicators associated with caries reduc-tion in the permanent dentition were:toothbrushing with fluoridated toothpaste1-2 times per day, dental appointmentsonce or twice per year, early signs of fluo-rosis (Carvalho et al. 2001b) high socio-economic status (Van Nieuwenhuysen etal. 2002, Carvalho et al. 2003) and Bel-gian nationality (Carvalho et al. 2003).

Adults

–

an epidemiological study onprevalence of periodontal disease indi-cated that never smoking is a good oralhealth indicator associated with periodon-tal health (Bercy et al. 2002).The health indicators identified in Belgianstudies are supported by the internationalliterature. The challenge is to determinetheir real impact on oral health and theirpractical implementation in publichealth.Most of all, it is important to appre-ciate that only the determinants, biologi-cal factors, are able to interfere with therate of disease progression and develop-ment. Non biological factors derive their

association with dental diseases inducedby microbial deposits only because theirare associated with the determinants andthrough these determinants with the dis-eases (Thylstrup & Fejerskov 1994).

References

Bercy P, Meurisse JB, Lambert ML, Tonglet R.Santé parodontale et besoins en soins parodon-taux d’un échantillon de la population belge.

RevBelge Méd Dent

2002; 57: 206-214.Carvalho JC, D’Hoore, Van Nieuwenhuysen JP.

Changes in caries in the primary dentition of chil-dren resident in Brussels, Belgium: socio-eco-nomic and ethnic aspects.

In press

2003,

Commu-nity Dent Oral Epidemiol

.Carvalho JC, Declerck D, Vinckier F. Oral

health status in Belgian 3- to 5-year-old children.

Clin Oral Invest

1998;

2: 26-30.Carvalho JC, Van Nieuwenhuysen JP, D’Hoore

W. Hygiène buccale et conditions gingivales desenfants de 12 ans dans la Région de Bruxelles.

Rev Belge Med Dent

2001a; 4: 281-290.Carvalho JC, Van Nieuwenhuysen JP, D’Hoore

W. The decline in dental caries among Belgianchildren between 1983 and 1996.


2001b; 29: 55-61.Carvalho JC, Vinckier F, Declerck D. Malocclu-

sion, dental injuries and dental anomalies in theprimary dentition of belgian children.

Int J PaedDent

1998 8: 137-141.D’Hoore W, Van Nieuwenhuysen JP. Applica-

tion de la méthode des traceurs à l’évaluation dela qualité des soins dentaires chez 3237 écoliersbelges.

Rev Epidém et Santé Publ

1991; 39: 63-69.D’Hoore W & Van Nieuwenhuysen JP. Une

illustration du concept de distribution sociale dela qualité des soins: à propos de la carie dentaire.

J Econ Méd 1991

; 9: 195-203.Declerck D & Goffin G. Etude épidémiologique

de la prévalence de caries chez les écoliers de 5et 12 ans en Flandre.

Rev Belge Méd Dent

1992;47: 9-23.

Declerck D, Vanobbergen J, Martens L, LesaffreE, Bottenberg P, Hoffenbrouwer K. Oral health of

122

children in Flanders (Belgium) 1996-2001. InDeclerck ed. 2002.

Gizani S, Vinckier F, Declerck D. Caries patternand oral health habits in 2- to 6-yera-old childrenexhibiting difffering levels of caries.

Clin OralInvest

1999; 3: 35-40.Lambert ML, Bertrand F, Prevost C, Tonglet R.

Les maladies parodontales parmi le personnel del’Université Catholique de Louvain (UCL): uneenquête des unités PARO/EPID. Mars 1997.

Thylstrup A & Fejerskov O. Textbook of Clini-cal Cariology. 2

nd

ed, Munksgaard, Copenhagen,1994

Van Nieuwenhuysen JP, Carvalho JC, D’HooreW. Caries reduction in Belgian 12-year-old chil-dren related to socio-economic status

. Acta odon-tol Scand

2002; 60: 123-128.Van Nieuwenhuysen JP, Carvalho JC, D’Hoore

W. Interpreting a decrease in DMF score in Bel-gian dental students from 1989 to 1994. LouvainMed 1998; 117: 243-249.

Van Nieuwenhuysen JP & Carvalho JC. OnDental Health in Belgian Population Approachingthe 21

st

century. Arch Public Health, 2000; 58:23-26.

Van Nieuwenhuysen JP, D’Hoore W, Vreven J.Etude de la carie dentaire dans une populationscolaire belge âgée de 5 à 21 ans. Rev Belge MédDent 1992; 47: 31-43.

Vanobbergen J, Martens L, Lesaffre E, BogaertsK, Declerck D. Assessing risk indicators for dentalcaries in the primary dentition.


2001a; 29: 424-34.Vanobbergen J, Martens L, Lesaffre E, Bogaerts

K, Declerck D. The value of a baseline caries riskassesssment model in the primary dentition for theprediction of caries incidence in the permanentdentition.

Caries Res 2001c

; 35: 442-50.Vanobbergen J, Martens L, Lesaffre E, Declerck

D. Parental occupational status related to dentalcaries experience in 7-year-old children in Flan-dres (Belgium).


2001b;18: 256-62.

Widström E, Kenneth AE. Systems for the provi-sion of oral health care, workforce and costs inthe EU and EEA – A council of European Chiefdental Officers’ survey – National Research andDevelopment Centre for Welfare and Health. Fin-land, 1999.

123

European Global Oral Health Project - Critical analysis of oral health determinants

Carina Källestål

1

Introduction

For this analysis of oral health determi-nants, oral health is understood as no pres-ence of the main oral diseases; dental car-ies and periodontal diseases. To besystematic a search for review articles wasmade in the bibliographic database Med-line for the period 1995 until June 2003with the search terms: Dental caries, Peri-odontitis, Determinant/s, Risk factor/s,Review. A list of 15 articles on caries waschosen and of these 12 was ordered andread in full text. For periodontal diseaseswere eight articles identified and five wereordered and read in full text.

Caries in small children, so called early childhood caries (EEC)

Low birth weight has, as a biological fac-tor, been suggested as a determinant forcaries later in life. The review by Burt &Pai (2001) failed to show any relationshipbetween low birth weight and subsequentdevelopment of caries. They are however,

cautious because of the scarcity of studiesand states that the question needs furtherresearch to be finally answered.Different behaviours has been suggestedas determinants for EEC as poor oralhygiene, limited exposure to fluorides andfrequent exposure to sugary snacks anddrinks (Ismail 1998a). Especially behav-iours as frequent use of sweetened feedingbottle, drinking soft drinks, and eatingsweets are pinpointed for development ofEEC (Ismail 1998b). The question if pro-longed breastfeeding is also a determinantfor EEC has been evaluated by a system-atic review (Valaitis et al. 2000). There aresome indications that breastfeeding forover one year and at night beyond erup-tion of teeth may be associated with EECbut there are conflicting findings and atpresent no definite time at which an infantshould be weaned can be determined.A factor which must be considered struc-tural is malnutrition which has beenshown to lead to delayed eruption of pri-mary teeth and possibly to increased car-ies prevalence (Ismail 1998b).

1. National Institute of Public Health, Unit for Intervention Research, Stockholm, Sweden.

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Caries in children and adolescents

For children and adolescents the behav-ioural factor sugar intake, particularlysucrose intake is the most important deter-minant according to a comprehensivereview by Sheiham (2001). Both the fre-quency of consumption and total amountof sugars are important in the aetiology ofcaries. Increase in frequency of sugaryintakes of more than four per dayincreases the risk for caries. Teenagers andadults intake of sugars should not exceed60g/person/day and for pre-school chil-dren it should not exceed 30g/person/day.Tooth brushing per se and thus, oralhygiene does not prove to be a determi-nant for caries. But the use of fluoridatedtoothpastes has been shown to be impor-tant for preventing caries.Structural factors as socioeconomic leveland ethnicity has proven to be strongdeterminants for caries (Sheiham 2001,Locker 2000). Several studies measuringsocioeconomic level in different wayshave shown that deprivation is associatedwith more caries. Also being an immigrantor belonging to a different ethnic groupthan the majority seems to be a determi-nant of dental caries.As a determinant for caries the past expe-rience of dental caries seems to be para-mount. This parameter is probably the bestpredictor of future caries in children(Messer 2000).

Caries in adults

Knowing that adults have similar inci-dence in caries as children (Sheiham2001) and thus, caries being a disease forthe whole life it seems odd that almost noscientific articles are published either on

epidemiology or determinants of caries inadult populations. No review on caries inadults was found. There is however, noreason to believe that the determinantsproven for adolescents should not be validalso for adults i.e., sugar intake and socio-economic determinants.

Caries in old and sick

Also for the old age groups there were noreviews identified. A problem most con-fined to older age groups is root caries.There are conflicting reports on the preva-lence and incidence of root caries due todiffering criteria and indices to expressresults (Clarkson 1995). The aetiology andthereby also determinants for root caries isnot clarified.A common clinical knowledge althoughnot reported in a systematic review is theincreased risk for caries in conjunction tocertain diseases and also with medica-tions. Diseases or treatment that impairsthe salivary flow are increasing the risk forcaries. So are also drugs that decrease sal-ivary flow or contain sugar. If these dis-eases and drugs should be considereddeterminants is however, a matter of defi-nition.

Periodontitis in children and adolescents

The definition of periodontitis is not clear(Jenkins & Papananou 2001) and new sys-tems for classification are seen in the liter-ature every other year. Albandar and Rams(2002) are however using four classifica-tions when describing periodontitis inyouth; periodontitis as a manifestation ofsystemic disease, necrotizing periodontaldisease, aggressive preiodontitis andchronic periodontitis.

European Global Oral Health Project - Critical analysis of oral health determinants

125

Systematic diseases associated with perio-dontal disease have a genetic aetiology asPappilon-LefËvre syndrome, Downís syn-drome, congenital neutropenia, leukocyteadhesion deficiency etc. Necrotizing peri-odontal diseases are associated withdiminished host resistance to bacterialinfection of periodontal tissues which mayoccur due to various environmental fac-tors as malnutrition, psychological andphysical stress, poor oral hygiene, alcoholuse and smoking. Necrotizing periodontaldiseases are more common in poor popu-lations of undeveloped countries.Aggressive periodontitis is characterisedby rapid loss of periodontal tissues wherethere might be a genetic predisposition butlocal factors also play a significant role.These include certain bacterial species,particularly

Actomycetemcomitans

and

P.gingivalis.

Furthermore, immune defects,poor oral hygiene, local plaque retainingfactors and smoking increase the risk ofdisease occurrence and progression.Aggressive periodontitis is more frequentin certain ethnic groups as African andHispanics.Chronic periodontitis is much more preva-lent than the other three groups of diseases.It is believed to be similar to adult chronicperiodontal disease. Poor oral hygiene,local plaque-retaining factors, and smok-ing are important etiological factors.

Periodontitis in adults

The definition of periodontitis is notclearer for adults but a definition based onclinical signs of lost periodontal tissueusually forms the basis for epidemiologi-cal research in the area. The principal eti-ological factors are microbiological dentalplaque biofilms, whereas several other

local and systemic factors have importantmodifying roles in the pathogenesis.Numerous behavioural and environmentalrisk factors are identified but only a few arewhat we could call determinants of the dis-ease. The two factors having overwhelmingevidence as determinants are smoking anddiabetes mellitus (Albandar 2002, Genco1996). For other factors are more researchneeded in order to establish accuratelytheir contribution in the pathogenesis.

Conclusion

From the above cited reviews it seems thatthe main determinants for caries, irrespec-tive of the age at which it occurs, are sugarintake and low socioeconomic level. Forthe sugar intake is both frequency andtotal amount of intake important.To judge from the literature there is ashortage of aetiological epidemiologicalstudies on adult caries. The influence ofdiseases, drugs and socioeconomic factorsare not reported on as often as for adoles-cents. Also, for caries in the older agegroups little is known of determinants forcaries which is also true for root caries.For periodontal disease it seems that smok-ing and diabetes mellitus are the maindeterminants except for some rare cases ofperiodontal disease at childhood whichhas genetic disorders as main determi-nants. The level of oral hygiene has equiv-ocal associations with periodontal diseasealthough it is an important factor for theaetiology. The main shortcoming for peri-odontal research is the lack of definition ofthe disease; it is unclear if there are severaldiseases or only one entity and how thisshould be defined. This is of course due tothe aetiology not being clarified but it ham-pers the selection of determinants.

126

References

Albandar JM & Rams TE. Risk factors for peri-odontitis in children and young persons.

Period-ontol 2000

2002; 29: 207-22.Albandaer JM. Global risk factors and risk indi-

cators for periodontal diseases.

Periodontol 2000

.2002; 29: 177-206.

Burt BA & Pai S. Does low birthweight increasethe risk of caries? A systematic review.

J DentEduc

. 2001; 65: 1024-7.Clarkson JE. Epidemiology of root caries.

AmJ Dent

1995; 8: 329-34.Genco RJ. Current view of risk factors for peri-

odontal diseases.

J Periodontol

1996; 67: 1041-9.Ismail AI. The role of early dietary habits in

dental caries development.

Spec Care Dentist

.1998; 18: 40-5.

Ismail AI. Prevention of early childhood caries.


1998; 26: 49-61.

Jenkins WM & Papapanou PN. Epidemiology ofperiodontal disease in children and adolescents.

Periodontol 2000

2001; 26: 16-32.Locker D. Deprivation and oral health: a

review. Community Dent Oral Epidemiol 2000;28: 161-9.

Messer LB. Assessing caries risk in children.

Aust Dent J

2000; 45: 10-6.Sheiham A. Dietary effects on dental diseases.

Public Health Nutr.

2001; 4: 569-91.Valaitis R, Hesch R, Passarelli C, Sheehan D,

Sinton J. A systematic review of the relationshipbetween breastfeeding and early childhood car-ies.

Can J Public Health

. 2000; 91: 411-7.

127


Anne Nordblad

1

and Annamari Nihtilä

2

Introduction

In Finland, the organization and financingof health care has been considered a pub-lic responsibility for a long time. The statedetermines the general health policyguidelines and directs the health care sys-tem at the national level. The municipali-ties have the main responsibility for arrang-ing health services. In general, legislationdoes not regulate in great detail the rangeand method of organizing the services. Themunicipalities can therefore arrange healthservices according to local circumstancesand the population’s needs.The amended provisions of PrimaryHealth Care Act and the Health InsuranceAct, which entered into force onDecember 2002, abolished the age limitsto publicly subsidised dental care. Beforethat the local authorities could limit theaccess to dental care on the basis of age,likewise the eligibility for reimbursementunder health insurance was determinedon the basis of age. The municipalities

have the main responsibility for arrangingoral health care services as well as healthservices in general. At the same time allclients of private dental care are, irrespec-tive of their age entitled to reimbursementfrom health insurance granted by the so-cial Insurance Institution according to theconfirmed prices.Organizing public oral health care servicesrequires careful strategic planning. Indica-tors used for collecting data of oral healthdeterminants and oral health care systemsshould serve the health strategy and healthgoals of the oral health services.The indicators need to be clearly defined.There are now differences between the Eu-ropean Union countries in defining theused indicators. The most important futuretask is the detailed description of useful in-dicators that enables the comparison be-tween different EU countries. Technicaldata collection is also an important issue.For comparisons between different coun-tries the data/used indicators should beavailable in Internet.

1. Ministry of Social Affairs and Health, Ministry of Social Affairs and Health, Health Department,Helsinki, Finland.2. EGOHID Consultant, Espoo, Finland.

128

This paper shortly describes the nationalhealth project proceeding in Finland, the in-dicators collected in national oral healthsurveys by the National Research and De-velopment Centre for Welfare and Health(Stakes), the new strategic planning in oralhealth care services in municipalities. As atechnical data collection example the Qual-ity Recommendations for Care and Servicefor older persons project is presented.

The national health project

The Council of State initiated a nationalproject to ensure the future health care inApril 2002. The key areas of developmentare concerned with health promotion andpreventive work, ensuring access to treat-ment, staff availability and the improve-ment of skills, reforming health carefunctions and structures and reinforcing fi-nancing. Concerning the access to treat-ment national guidelines for non-urgenttreatment and queue management are be-ing prepared.The principles of access to treatment withina reasonable period of time will be embod-ied in legislation by the year 2005. The ba-sic premises of preparation are access ofpreliminary assessment of health withinthree days of contacting the service, accessto outpatient assessment by a specialistwithin three weeks of referral and access tomedically justified treatment assured withthe time specified by the national treatmentrecommendations. These basic principleswill concern also oral health care but arebeing modified and developed in detail fororal health care. Measuring the access totreatment would be a useful indicator.Supplementary training for health carepersonnel will be regulated and increasedtaking specific regional needs into consid-

eration. Supplementary training for healthpersonnel will be mandatory. At the mo-ment supplementary training is not man-datory for dentists.The finances of health care will be aug-mented. The need for additional funding isa result of the increased demand for ser-vices caused by the change if the agestructure of the population, the introduc-tion of new technology and the additionalcosts arising from attaining the standardsrequired by in-service training and qualityrecommendations.

Indicators used in national oral health surveys

In Finland national information of opera-tion of the public sector oral health careand its effect on the oral health status ofthe population has been collected since1970-1971. From 1980 national oralhealth surveys have been carried out everythree years. The respondent rates from thehealth centers have been high (varyingfrom 88% to 98%). Now that all Finns areentitled to subsidized dental care (sinceDecember 2002) information is graduallycollected of entire population. Informationis gathered of the number of oral healthpersonnel (dentists, chief dentists, special-ized dentists, dental hygienists, dental as-sistants) and the cost and financing oralhealth care. In the year 2000 survey thefollowing indicators were used to collecttotal health status data: the age group andtotal number of age group, percentage ofexamined, dental visits, caries free, per-centage of attending orthodontic care,d-index and dmf-index, CPI-index, seal-ants, fillings, percentage of edentulous, atleast 20 functioning teeth, endodontictreatment, extractions, users of removable


129

dentures. The data has been summarizedusing the following age groups: 0-5, 6-18,19-44, 45-64, 65-74, –> 75.These national oral health surveys havebeen very important in estimating efficacyof the public oral health services and inimproving their performance

Organising public oral health care services requires careful strategic planning

The Balanced Scorecard method (BSC) hasbeen proved to be an effective strategicplanning tool in public sector oral healthcare. The idea is that crucial success fac-tors based on vision and strategy can beused as indicators describing how well op-erations are being carried out, and theseindicators can in turn be used for monitor-ing and measuring, and in comparisonsbetween health centers.The BSC method is based on four view-points: those of civic and political decision-makers, resource management and finance,the organization’s performance and func-tionality, and the workplace community andstaff. The essentials for strategic success fromeach of these viewpoints are crystallized ascrucial success factors. These factors weredefined according to four viewpoints: per-formance, resources, process and renewal.The evaluation criteria picturing the successfactors in oral health care contain informa-tion that both describe and guides opera-tions. This basic information can be used tocreate new derived indicators. Indicatorscan also be used to clearly express the de-sired direction or the desired standard aimedat. Indicators of this type are for examplecustomer satisfaction index, DMF index, aservice-use index illustrating the organiza-tion’s conscious care policy plus indicesmeasuring efficiency and productivity in the

production of services. In this method theuse of common indicators in comparing or-ganizations have been considered useful.

The technical data collection and follow-up

As an example of a technical data collec-tion in Finland the quality indicators forevaluation of care and services for olderpersons project is presented. The FinnishMinistry of Social Affaires and Health andThe Association of Finnish Local and Re-gional Authorities issued in May 2001Quality Recommendations for Care andService for older persons. To support mu-nicipalities in bringing these recommenda-tions to practice STAKES (www.stakes.fi)has in collaboration with various municipalprofessionals collected these indicators. In-cluded are 19 key indicators and variousindicators covering 75 topics of data onmost significant parameters of care and ser-vice for older persons. The indicator groupsare the following: key indicators, demogra-phy, care structure, indexes for care loadand disability, coverage of age groups byservices, process and intensity of services,indicators on personnel, indicators oneconomy, planning and informing.This information is available of all 451Finnish municipalities. A demo version isavailable in the Internet.

References

Government Resolution on the Health 2015public health programme. Ministry of SocialAffairs and Health. Publications 2001: 6.

Health 2015 Public Health Programme. Ministryof Social Affaires and Health. Brochures 2001: 8.

Konttinen M. Ensuring the future of Finnishhealth care. Dialogi (in English) 2003; 6.

Nordblad A, Hiekkanen S, Helminen S, LinnaM, Varsio S. Strategic planning in oral health careservices. Dialogi (in English) 2002: 8.

131

Oral Health Indicators: Achievements and Perspectives

Are the “Quality Adjusted Life Years” and “Disability Adjusted Life Years” indi-ces trustworthy?

Gérard Duru

Oral Health Indicators in Europe: Preliminary consultation on the informationavailable in 15 EU countries.

Nicolas Nicoloyannis, Marie Hélène Leclercq and Denis M. Bourgeois

133

Are the “Quality Adjusted Life Years” and “Disability Adjusted Life Years” indices trustworthy?

Gérard Duru

1

Any action undertaken in the field of healthuses resources and produces either positiveor sometimes negative results. These resultsare generally described by two indices: anindex of medical effectiveness consideredrelevant to the context of the action, plus ei-ther a quality-of-life (QOL) index or else anindex of dependency.One of the most widely used medical effec-tiveness indices is the number of years oflife gained. There are, in contrast, a largenumber of quality-of-life indices, classifiedaccording to the “states of health” (alsoknown as “states of life”) taken account ofand how each such state is weighted. Tosimplify matters, there may be taken to betwo main categories of quality-of-life index:• Those in which states of health are

defined in terms of response profiles ona closed, so-called “quality of life”

questionnaire. The value associated toeach state is obtained by scoring.

• Those in which states of health aredescriptive. They are classified accord-ing to patient preferences. The valueassociated to each state is a numericcode representing the ranking given bythe patient. The process whereby thisvalue is associated to the state of healthis called a “utility function”, and thevalue itself is called the “utility” of thestate of health in question

2, 3, 4

.The same holds true for dependencyindices.It is obviously a good idea to be able tocompare results from two (or more) ac-tions in the field of health. And this is easyto do when all of the results are expressedin terms of the same index, but becomesmuch more complex when two different

1. University Lyon I, France.

2. A. Béresniak, G. Duru, Économie de la santé [Economics of Health], collection des Abrégés,

Masson, 5

th

édition, 216 pages, Paris, August 2001.3. G. Duru, Utilité, in Dictionnaire des Sciences Économiques [Dictionary of Economic Science],C. Jessua, C. Labrousse, D. Vitry eds, PUF, 1096 pages, Paris, April 2001.4. J.P. Auray, A. Béresniak, J.P. Claveranne, G. Duru, C. Murillo, Diccionario comentado de eco-nomia de la salud [Dictionary of Health Economics, with Commentary], handbook, Masson, 351pages, Barcelona 1998.

134

indices are involved. In point of fact, dif-ferent indices can lead to different conclu-sions: action A may be deemed better thanaction B in terms of medical effectiveness,while B seems to be better than A in termsof quality of life. This is the whole problemof multi-criterion analysis.One elegant way of solving this problem isto construct an index which performs auseful synthesis of the other two. Such anapproach has given rise to two indices:QALY (Quality-Adjusted Life-Years), com-bining a QOL index on the one hand, and“years of life gained” as an indicator ofmedical effectiveness on the other; andDALY (Disability-Adjusted Life-Years),combining a dependency index with and“years of life gained” as a medical effec-tiveness index.How is such a combination achieved? Theprocedure consists in weighting the num-ber of life-years gained by the quality-of-life (or dependency) index associated withthe state of health (or of dependency) inwhich they are going to be spent. The de-termination of the combination function issaid to be

multiplicative.

This is all very straightforward, not onlymathematically but also from the point ofview of interpretation. Take, for example,the case of an action which enables the sub-ject to gain 10 extra life-years, which will bespent in a wheelchair. If the index valuecorresponding to the state of life referred toas “moving around in a wheelchair” is 0.5,then the combined index value will be giv-en by 10

×

0.5 = 5. And if a state of life re-ferred to as “disability-free” is indexed at avalue of 1, then this combined value of 5will also correspond to “5 extra years lived

without disability”. I.e., “living 10 extrayears in a wheelchair” is equivalent to “liv-ing 5 extra years without disability”.One should sometimes be wary of thingswhich look simple, not to say

simplistic.

And such is the case with the specificationsunderlying the QALY and DALY indices

1

.Two examples will serve to illustrate this.

The first example

concerns the comingwinter sports season. Being as we are aworried and anxious kind of person, weare thinking about the accidents whichcould happen to us. By the time the seasonis over, a bad fall may have us walking oncrutches or with the help of a cane. Thenagain, we could fall over a cliff and eitherdie, or end up bed-ridden, or confined toa wheelchair. Looking on the brighterside, we may equally well emerge fromthe coming season as from those that pre-ceded it: i.e., with mobility unimpaired.Any of these states of life and of health arepossible consequences of our love of ski-ing. And we can, of course, rank them inorder of preference. I imagine most skierswould agree with the following classifica-tion: “unimpaired mobility” is preferableto “using a cane”, which in turn is betterthan “being in a wheelchair”, which ispreferable to “being bed-ridden”, not tomention “dead” – although there are thosewho feel that being bed-ridden is a fateworse than death.Having drawn up this personal preferenceranking, let us then ask ourselves whatmay seem to be a rather curious question:would we prefer to live 20 years movingaround in a wheelchair, or just 10 years,but on crutches?

1. Duru G, Auray J.P., Béresniak A, Lamure M, Paine A, Nicoloyannis N. Limitations of the meth-ods used for calculating Quality-Adjusted life-year values,

Pharmacoeconomics

; 2002 20 (7).


135

We are, we confess, unable to give an an-swer. So let us consult two of our friendswho are experts in the matter, Robert andClaude, and ask them to design a protocolto help reveal our actual preferences asbetween these two outcomes.Their advice to us is: “You should firstconstruct a

utility

function associated tothe preference relations or the ranking ofhealth-states you have drawn up; this is tobe done by means of a

standard gamble,

which is an experimental means of associ-ating an utility value to each life-state.”Having done this, our two experts suggestconstructing an index taking account ofthe duration and of the value attributed tothe various states of mobility, by weightingthe life-years by the utility value of thestate of health in which the years would belived. This is how indices such as QALYand DALY are determined.As scientists, we are rather reticent aboutany new method, and so we get the repro-ducibility of Claude and Robert’s methodchecked by asking them to carry out theexperiment separately.Here, then, is Robert’s experiment:The

standard gamble

consists in offeringtwo different contracts. The first states that:“Your accident means you have to walkwith crutches”, and the second that: “Thereis a highly skilled surgeon who could oper-ate and restore full mobility, although hisoperations are not always a success. Thereis thus a probability

p

of your recoveringfull mobility if you agree to the operation,but also of course a probability 1-

p

of end-ing up bed-ridden.” If

p

equalled 1, weshould obviously not hesitate to take ourchances in surgery. But, if

p

= 0.99, wouldwe still risk being operated even with 1chance in 100 of ending up bed-ridden?The experiment consists in varying

p

so as

to discover the

p

-value at which the twocontracts seem to the subject to be equiva-lent. This is a technique widely used on theother side of the Atlantic.Robert attributes a value of 1 to the state of“unimpaired mobility”: it is his chosenunit-value of measurement. And the stateof being “bed-ridden” scores 0, as thepoint of origin for the parameter Robertchose for measuring the utility value ofstates of health.In science, all measurement is made alonga parameter defined by the choice of apoint of origin and of a unit value.The results of Robert’s experiment are asfollows:The two contracts are found to be equiva-lent when

p

= 0.3. Robert thus assigns avalue of 0.3 to the state designated by“walking with crutches”.The same procedure is followed for thestate designated by “moving around in awheelchair”. In this case, the contracts arefound to be equivalent at

p

= 0.1, whichthus represents the utility value of “movingaround in a wheelchair”.Now we simply have to calculate the num-ber of QALYs for each situation, as theproduct of the number of life-years multi-plied by the utility value of the state ofhealth in question. “20 years in a wheel-chair” thus scores 20

×

0.1 = 2 QALYs,which is the equivalent of “2 years of lifewith unimpaired mobility”. And “10 yearswalking with crutches” scores 10

×

0.3 = 3QALYs, making it the equivalent of “3years of life with unimpaired mobility”.So Robert tells us, “You obviously preferthe idea of living just 10 years with crutch-es to 20 in a wheelchair.”Claude runs the same experiment, but notwith the same unit-value or point of origin.No problem: he has simply chosen a dif-

136

ferent parameter, with its origin at “death”and the unit-value corresponding to“walking with the help of a cane”.The results of Claude’s experiment are asfollows:When the state of health in the first con-tract is “walking with crutches”, the twocontracts are equivalent for

p

= 0.7; andwhen the state of health in the first con-tract is “moving around in a wheelchair”,the two contracts are equivalent for

p

= 0.5.Thus the number of QALYs correspondingto “20 years in a wheelchair” and “10 yearson crutches” are respectively 10 and 7.And Claude tells us, “You obviously preferthe idea of living 20 years in a wheelchairrather than 10 years with crutches”. I.e.,his conclusions run counter to Robert’s, al-though the same experimental design wasused. All that changed was the parameter.This example goes to show how sensitivethe QALY index is to the choice of param-eter. You choose your parameter, and getyour result!

A second example

is intended to showthat one should beware of so-called“league tables”

1

, comparing series of in-terventions in terms of QALY cost-effec-tiveness.Let us imagine 2 articles, published ininternational peer-review journals, pre-senting the cost-per-QALY of two inter-ventions, one for pathology X and theother for pathology Y.The first article estimates the cost-effective-ness (cost per QALY) of an intervention for

pathology X, from society’s point of view,with QOL measured on Rosser’s grid

2

, andfinds a ratio of

O

2,067 per QALY.

The second article uses the same method,and assesses the cost-effectiveness of anintervention for pathology Y at

O

1,770 perQALY.

The intervention for pathology Y is thuspreferable to that for pathology X.Both articles present a cost-effectivenesanalysis for the respective interventions.And both have the same cost:

O

10,000.

The first intervention, for pathology X,gives a gain of 7 extra life-years: the first 3years are spent in a state described on theRossner grid as “slight physical dysfunc-tion and no emotional suffering”; the next2 are spent in a state of “significantly lim-ited activity, and mild emotional suffer-ing”; and the last two years are spent in astate of “significantly limited activity, andsignificant emotional suffering”.The second intervention, for pathology Y,gives a gain of 6 extra life-years: the first isspent in a state of “slight physical dysfunc-tion and no emotional suffering”, the nexttwo in a state of “significantly limited ac-tivity, and mild emotional suffering”, andthe last three in a state of “significantlylimited activity, and significant emotionalsuffering”.It is clear that the results of the first inter-vention are better in terms of medical ef-fectiveness and quality of life. But,strangely, for the same cost the cost-effec-tiveness ratio gives the advantage to thesecond intervention. How is such a para-dox to be explained?

1. Masson J., Drummond M., Torrance G., Some guidelines on cost effectiveness league tables,

British Medical Journal

1993; 306: 510, 572.2. Gudex C, Kind P, The QALY Toolkit, Discussion paper 38, Centre for Health Economics, Uni-versity of York.


137

The paradox is in fact more apparent thanreal. In the first article, the author usesRosser grid health-state values derivedfrom physicians’ preferences. The utilityvalues which physicians assign to states of“slight physical dysfunction and no emo-tional suffering”, “significantly limited ac-tivity, and mild emotional suffering” and“significantly limited activity, and signifi-cant emotional suffering” are respectively0.981, 0.760 and 0.187, which results in aQALY number of 4.837 and a cost-effec-tiveness ratio of 10,000/4.837 = 2.067.In the second article, the author also usedthe Rosser grid, but derived the corre-sponding values from preferences ex-pressed by nursing staff. The utility valuesassigned here to states of “slight physicaldysfunction and no emotional suffering”,“significantly limited activity, and mildemotional suffering” and “significantlylimited activity, and significant emotionalsuffering” were respectively 0.992, 0.963and 0.911, giving a QALY number of5.651 and a cost-effectiveness ratio of10,000/5.651 = 1,770.The apparent paradox is no paradox at all,but just the kind of stupid mistake a badpupil might make by trying to compare,say, physics results expressed in divergentunits of measurement.The fact is that, in league tables, the pa-rameter used in the calculation of cost-ef-fectiveness is never stated; the results aretherefore to be taken with the greatest pru-dence. Justifying QALYs by insisting, as isso frequently done, that “a QALY is a QA-LY”

1

is more like claiming that “a length isa length” than that “a metre is a metre”!

Just try to imagine what would happen toair traffic control if the altitudes of planesusing altimeters in feet were to be setagainst altitudes of planes using altimetersin metres, without specifying which unitthe altitude was being measured in.

These two simple little examples explainwhy the French pharmaco-economicguidelines

2

are so reserved as to the use ofthis kind of index. In conclusion, let usquote from guideline n° 25:“The QALY approach consists in combin-ing in a single dimension two dimensionsdescribing the results of an action in thehealth field in terms of life-years gainedand of quality of life. The combinationprocedure raises a number of issues, bothmethodological and philosophical

The lack of robustness in the approachmeans that the conclusions drawn from astudy can be manipulated.“This leads us to advise readers or users ofstudies with results presented in terms ofQALY to look carefully at the followingconditions:“a) In each case it is vital to check

whether the reference for the quality-of-life measure and the measurementmethod used are stated, and that themultiplicative combination functionhas been validated.

“b) The origin of the quality-of-life mea-sures needs to be considered, and inparticular whether they are psycho-metric or else derived from prefer-ence-revelation techniques such asTTO or standard gamble.

1. Williams A, Cost-effectiveness: is it ethical?

J. of Medical Ethics

, 1992; 18: 7-11.2. La lettre du Collège des Economistes de la Santé, Juin 2003.

CES Website: http://perso.wana-doo.fr/ces/

138

“c) When versions of QALY are beingused which rely on theories of utilityor expected utility, the reader needs toconsider whether the behaviouralhypotheses and methodological andepistemological choices have beenvalidated and what biases suchchoices may entail.

“d) In all cases, any attempt to make com-parisons between studies and patholo-gies (e.g., league tables) should beviewed with the greatest caution: forexample, one should check whetherthe same systems of reference havebeen used in the various cases. Nor isit advisable to take the health-state

valuation from one study and use it inanother, without first carefully validat-ing the equivalence of the states ofhealth.

“e) One should also be wary of the risk ofdistribution bias if comparisons aremade between populations with verydivergent socio-demographic charac-teristics or varying preferences for thetreatments under analysis.

“f) In the present state of research, it isunadvisable to base any public deci-sion on study results expressed interms of QALY, given the possibility ofgenerating divergent results from thesame observed data.”

139

Oral Health Indicators in Europe: Preliminary Consultation on the Information available in 15 EU Countries

Nicolas Nicoloyannis

1

, Marie Hélène Leclercq

2

and Denis M. Bourgeois

3

Introduction

The research project to set up a EuropeanConsultation on statistical methods fororal health, involving the availability ofindicators has been instigated and ear-marked by the group members of theEGOHDP, as a research field to be pro-moted in view of its potential utility for theelaboration of a long list of oral healthindicators.The improvement observed in the status oforal health in the population of the industri-alized countries has prompted the scientificcommunity, professional bodies and deci-sion-makers to ask which indicators policystrategies ought to be adopted in relation tosurveillance in the future. This transitionperiod provides a timely opportunity foridentifying precisely these future optionsand objectives in oral health surveillance.This project is part of the wider attempt toidentify indicators for oral health (prob-lems, determinants and risk factors related

to lifestyle), indicators for critical oralhealth care, the quality of care, for essen-tial health resources and to identify thetypes of data generation and managementproblems within the health informationsystem

for long-term surveillance oralhealth among the European population.The concept of development of opera-tional indicators in oral health has beenproposed in Europe (Biomed, Oratel,etc…) and in the world. So, in an unpub-lished WHO paper, Leclercq and al. in1991 had already described the corner-stone and the need for an oral care man-agement system. It was derived from fourareas of concern:• The lack of standard and reliable infor-

mation for planning and monitoringcare services;

• The change in the pattern of dental dis-eases and periodontal diseases andtreatment and the implication for con-ventional epidemiological survey meth-ods;

1. EGOHID Consultant, Lyon, France.2. University of Lyon, France.3. Faculty of Dentistry, University of Lyon, France.

140

• The need to expand the sources ofinformation beyond the standard epide-miological type of survey;

• The variety of existing systems.

A high priority was to encourage thedevelopment of standards for the designand implementation of computerized sys-tems for the management of oral healthcare. A goal was to seek a level of agree-ment sufficient to allow comparability ofdata that are conceptually equivalent andpermit clear delineation of data.Moreover, in 1992, the WHO ExpertCommittee on Recent Advances in OralHealth pointed out in the TechnicalReport 826 that the objective of informat-ics developments in the advancement oforal health was to encourage the develop-ment and implementation of standards forclinical records, so that the benefits ofinformation management can serve thedecision-making process and allowappropriate oral health care to be imple-mented.Thus, the goal

of this consultation is notintended to question the utility of indica-tors as a method of surveillance but toreconsider, in view of continuing scientificuncertainty in respect of this issue, howindicators should best be used within acommunity. Informed by the hard knowl-edge and grey areas surrounding this issuethese recommendations replace currentindications for indicators utilisation.For instance, dietary habits that increasethe risk of overexposure of infants andyoung children to fluorides from differentsources should be identified and appropri-ate surveillance measures taken. The effi-cacy of all caries prevention programmesshould be periodically evaluated. InEurope, where caries prevalence is moder-

ate to low, a cautious fluoride policyshould be adopted. There are, however,some concerns: authorities may reducetheir commitment to an oral health pre-vention policy that threatens to be the vic-tim of its own success, scientists mayquestion the validity of prevention in thelight of its drawbacks, and consumergroups may then politicize this movement.As our knowledge stands at the presenthowever, caries cannot be said to be erad-icated. Should there be a loss of momen-tum in prevention, caries will againbecome common. We take the view thatthere remain many groups at risk forwhom a specific approach is required.How is oral health surveillance likely todevelop? What will be the attitude offuture generations to dental caries when,like their parent’s generation, they have nodirect knowledge of caries? Is there not arisk that we will see inappropriate behav-iour with regard to oral health prevention?There is therefore substantial thematicmaterial to guide public health policy foradministration. Oral health is clearly in atransition period, which is not to questionthe utility of indicators. This transitionperiod provides an opportunity for identi-fying major trends and possible scenariosin oral health policy issues in the future.This initial consultation within the EUOral health SANCO project should beconsidered in this light. Its terms are intrin-sically part of the current debate but con-sensus should also move beyond thisframework especially since a wide varietyof indicators delivering products of com-parable efficacy is currently available.

The objectives of this consultation were tofacilitate the achievement of the EU Work-shop on Oral health statistics by:

Oral Health Indicators in Europe: Preliminary Consultation on the Information available in EU

141

• Presenting a review of the current situa-tion in respect regarding oral healthindicators relating to health problems,risk factors and determinants as well asan initial evaluation of action under-taken.

• Facilitating the reflexion of the variousparties involved in the project in the EUregion, on the availability of indicatorsat regional and national levels.

• Stimulating critical thought on the partof public health administrators on thefuture role of indicators in relation tooral health policy.

This consultation took place from 10 Mayto 25 August 2003 within the frameworkof the preparation of the EU workshop onstatistics in Oral Health held in Lyon inSeptember 2003.It was the first phase of the developmentprocess towards the elaboration of a longlist of oral health indicators as described inthe protocol of the EGHODP.

Methodology

Ideally, the prioritized indicators wouldalready be routinely monitored in a major-ity of Member States, or easily added tocurrent data. To ascertain what wasalready available, a questionnaire wasdevised to identify for which of the indica-tors information was currently available.The final first list of indicators thus, wasable globally to reflect the current avail-ability of information in the participatingcountries.A search of relevant literature was under-taken to establish for which indicators aclear link with disease had been estab-lished. Methodologies available to meetthe objectives of this project come within

the purview of so-called consensus sur-veys. Investigation comprised threephases:• Bibliographic research to identify cur-

rent thinking on methods of administer-ing indicators and to identify emergingtrends.

• Methodological research to enhanceand optimize the efficiency of consen-sus research fields applied to the topicspreviously identified.

• European consultation involving corre-spondence, meeting between theExperts Working Group of the EGO-HDP.

Administratively, the study required a sci-entific project leader, a consultant forproject implementation and follow-up.Technically, it comprised two phases: (i): apreliminary phase to decide on the work-ing design and the technical procedures;(ii) a general development phase to definethe main list of indicators and questionslinked to future fluoride use.The following took place during thisphase: (i) Information collation providedby secondary sources (references, statisti-cal sources) and provided by collection ofqualitative information (interviews withspecialists, symposia, etc.): (ii) Listing offactors determining methods of oral dis-ease surveillance linked to indicators use.Indicators were recorded based on the fol-lowing variables:• Variables linked to risk factors;• Variables linked to oral health status;• Variables linked to quality of life;• Variables linked to the oral health sys-

temsProject planning was under the jurisdic-tion of the Group Leader committee, Uni-versity Lyon, France. It comprised various

142

steps: (i) Defining administrative and orga-nizational structures for the process; (ii)Defining questionnaire items; (iii) Draftingand publishing the questionnaire; (iv) Val-idation of an expert panel; (v) Mailing ofthe questionnaire and correspondingadministrative work; (vi) Data analysis andfinal report.

Selection of participants

The expert panel group consisted of 15persons, national members of the Euro-pean Group. Nineteen different countrieswere represented. Each of the membersreceived an explanatory letter attached tothe questionnaire inviting them to join theconsultation in May 2003.The response rate was 100%. The nationaldistribution was: Austria, Belgium, Den-mark, France, Finland, Germany, Greece,Ireland, Italia, Netherlands, Norway, Por-tugal, Spain, Sweden, and United King-dom. The Consultation study comprisedone phase, beginning in May 2003 andfinishing in August 2003. The study wasco-ordinated and run from the EOHDPheadquarters in Lyon. All questionnairesand study data were dispatched to theprincipal investigator by mail and/or elec-tronic means (e-mail and fax).

Structure of the questionnaire

The technical committee decided, basedon initial discussion and arguments fromthe participants, which items and ques-tions should appear in the questionnaire.According to most of ongoing SANCOprojects, table of essential useful informa-tion, guidelines and recommendations

were adapted from the “European Com-munity Health Indicators Project” (ECHI),SANCO Project.

1

. Similarly, the identifi-cation of four primary categories of indica-tors “Demographic and socio-economic;Oral Health Status and Well being; Deter-minants of Oral health, Risk and protec-tive factors; Health Systems and Policy”was recommended.Open questions related to the structuredquestions allowed due consideration to begiven to arguments during the first phase.The target of this first questionnaire wasprincipally to provide an overview of indi-cators in oral health and principal limita-tions to their administration.

Analysis

The analysis of the questionnaire focusedon identifying problems and tried to estab-lish which forms of indicators deliverymight acquire future importance. 15 Euro-pean countries are examined for their con-siderations of relevant indicators. This syn-thesis is based on the analysis of singlecountry contributions channelled throughthe Group members according to theframework document provided. Bothqualitative and quantitative analyses weremade of answers to the consultation. Sin-gle country documents are not annexed.Detail of the results is available onrequests to the co-ordinator Group Leader(DB).

Oral health indicators mentioned by the countries

All participating countries answered posi-tively and 15 completed questionnaires

1. europa.eu.int/comm./health/ph_projects/monitoring_Project_en.htm


143

were received and analysed. A total of 66indicators were proposed qualifying 4areas related to oral health: Oral healthdeterminants listing 10 indicators, oralhealth status – 14 indicators, Oral healthsystems – 23 indicators and oral quality oflife based on recording 9 indicators. Inaddition 10 indicators on demographyand socio-economic factors stratified byage-groups were indicated.The results of the compiled informationare presented in two series of tables:•

The total number of indicators

availablein each country from the list of 66 indi-cated

•

The number of indicators

available ineach country,

in each of the 5 domains

:Demography and socioeconomic infor-mation, Oral health determinants, Oral

health status, Oral health systems, Oralhealth related quality of life. This infor-mation is illustrated by a series of bar-graphs.

•

The number of countries

declaring thatinformation is available,

by specificindicators.

This information is shown ina series of tables incorporated in thetext below.

The results have been computed on thebasis of answers qualified by codes A andB as defined in the criteria proposed by theECHI system: A- regularly available frominter national source, B- regularly avail-able from national source.The comments received stressed the needto better qualify the data source and atleast to indicate the frequency and thegeographical area in different categories.

Figure 1. Total number of indicators per country

0

10

20

30

40

50

60

70

Irel

and

Net

herla

nds

Uni

ted

Kin

gdom

Fin

land

Spa

in

Sw

eden

Ger

man

y

Den

mar

k

Fra

nce

Aus

tria

Nor

way

Bel

gium

Por

tuga

l

Italy

Gre

ece

Data available on a regular basis from international or national sources

144

As illustrated by the bargraph, the totalnumber of 66 indicators is out of reach forall countries. However, there are impor-tant discrepancies among the differentcountries, a group of seven claiming avail-ability of 30 (plus or minus 4) i.e. abouthalf of the group having less than half ofthe requested information. Two countriesrecording less than 10 and, at the otherend, one outstanding value of 62. Thisreflects a) the relative scarcity of the infor-mation available b) tremendous inequali-ties in the oral health information systemsin place in various European countries.

Looking at the same type of information,distributed by the 5 domains listed, pro-vides additional information on areaswhere the biggest gaps can be expected,or on the contrary where information isreasonably available.The section on Demography and socio-economic factors is an area where infor-mation can be obtained in all countries,80% to 100% of the data set are found in9 countries and there is only one countrywhere only 40% is recognized to be avail-able

(Figure 2)

.

The distribution of the availability of the

oral health determinants

indicators reflectsa bigger discrepancy, ranging from 3 coun-tries with 80% to 100% of the informationavailable, to 3 countries claiming not hav-ing any information at all in this domain:Italy, Greece and Portugal. The other groupof countries is distributed between 10 to50%, as illustrated in figure 3.

The fourth graph shows the informationthat can be obtained by recording 14 indi-cators on

oral health status

. All countrieswith one exception – Greece – have infor-mation available on oral health status. Thehighest number of indicators available is11 (out of 14 listed) available in 3 coun-tries.The fifth area investigated relates

to oralhealth systems

(figure 5)

recorded by

Figure 2. Demography and socio-economic factors,10 indicators

10

9

8

7

6

5

4

3

2

1

0

Irel

and

Den

mar

k

Uni

ted

Kin

gdom

Bel

gium

Net

herla

nds

Sw

eden

Fin

land

Nor

way

Ger

man

y

Por

tuga

l

Italy

Spa

in

Fra

nce

Gre

ece

Aus

tria

Data available on a regular or incidental basis, from international, national or regional sources



145

23 indicators: 6 countries have 0 to 5 indi-cators only – Norway, France, Germany,Greece, Portugal, Italy and only 2 coun-tries – Ireland and the Netherlands haveaccessible information with respectively23 and 19 indicators recorded.

Lastly, looking at

figure 6

recording theavailability of 9 indicators on oral healthrelated quality of life reveals, as wasexpected, the scarcity of the informationavailable. It is in this area that the gaps aremost striking and deep inequality exists in

Figure 3. Oral health determinants, 10 indicators

Figure 4. Oral health status, 14 indicators

12

10

8

6

4

2

0

Irel

and

Sw

eden

Fra

nce

Fin

land

Net

herla

nds

Den

mar

k

Ger

man

y

Italy

Nor

way

Uni

ted

Kin

gdom

Bel

gium

Por

tuga

l

Spa

in

Gre

ece

Aus

tria



0

2

4

6

8

10

12

Spa

in

Uni

ted

Kin

gdom

Net

herla

nds

Sw

eden

Fin

land

Por

tuga

l

Irel

and

Den

mar

k

Italy

Gre

ece

Aus

tria

Nor

way

Ger

man

y

Fra

nce

Bel

gium



146

respect of existing oral health informationsystems. As shown in

figure 6

, 11 coun-tries have no information at all (coded aand b), only little information is availablein one country and only 3 have all 9 indi-cators available.

Number of countries by specific indicators

A series of tables have been computed thatare showing the information available bycountries and each of the indicators in thefive areas covered.

Figure 5. Oral health systems, 23 indicators

Figure 6. Oral health related quality of life, 9 indicators

0

5

10

15

20

25Ir

elan

d

Net

herla

nds

Den

mar

k

Fin

land

Nor

way

Uni

ted

Kin

gdom

Spa

in

Bel

gium

Sw

eden

Fra

nce

Gre

ece

Por

tuga

l

Ger

man

y

Italy

Aus

tria



109

87654321

0

Irel

and

Fin

land

Fra

nce

Ger

man

y

Den

mar

k

Sw

eden

Nor

way

Uni

ted

Kin

gdom

Bel

gium

Por

tuga

l

Italy

Spa

in

Gre

ece

Aus

tria

Net

herla

nds




147

Clearly, whereas the previous set ofbargraph provides in a nutshell an immedi-ate picture of the areas where most or leastinformation is available, the distribution byspecific indicators provides a sharperapproach to where the major problem ininformation collection may be. One of theimportant criteria that will need consider-ation in further developments of this workwill be the feasibility of obtaining the infor-mation either from existing systems or from

surveys. These tables may be a help in pro-viding initial directions of thinking.As was expected,

demographic informa-tion

of general nature with no specific linkto oral health is largely available in allcountries

(table 1)

. Nevertheless, impor-tant gaps in the area of socio-economicfactors are recurrent in Italy, Greece, Aus-tria, Spain, France when looking at indica-tors related to oral health care services.

Table 1. Demography and socio-economic factors

Med

ian

age

of p

opul

atio

n

% p

opul

atio

n un

der

15

% p

opul

atio

n 65

and

ove

r

Popu

lati

on

proj

ecti

ons

Empl

oym

ent/

unem

ploy

men

tt

% p

opul

atio

n by

occ

upat

iona

l cla

ss

% p

opul

atio

n co

vere

d by

OH

ser

vice

s

% p

opul

atio

n un

der

15

% p

opul

atio

n 35

-44

% p

opul

atio

n 65

and

ove

r

Portugal

+ + + + +

Finland

+ + + + + + + + +

Italy

+ + + +

Norway

+ + + + + + +

Denmark

+ + + + + + + + + +

Sweden

+ + + + + + + + +

Netherlands

+ + + + + + + + +

Belgium

+ + + + + + + + + +

Greece

+ + + + + +

Austria

+ + + + +

Germany

+ + + + + + + +

Spain

+ + + + + +

United Kingdom

+ + + + + + + + + +

France

+ + + + + +

Ireland

+ + + + + + + + + +

Total

12 14 14 13 15 14 8 8 8 8

148

The absence of information regarding themedian age of the country populationsignaled by Portugal, Italy and Norwaymay be explained either by the absenceof a direct source or could relate by amisunderstanding of the questionnairelayout. In any case this could easily becalculated by existing demographicinformation in all three mentionedcountries.

Looking at the distribution of indicators on

oral health determinants

(table 2)

pro-vides a very different picture.More than half of the group claim not hav-ing any information on perceived oralhealth, knowledge/attitudes and percep-tion of the oral health system. This gap isnoted in all Scandinavian countries exceptSweden, in UK, and Greece. Adding Aus-tria, Spain and Belgium, countries withonly one indicator indicates that 10 coun-tries have none or very little information.

Table 2. Oral health determinants

Personnal factors Oral health behaviour

Perc

eive

d or

al h

ealt

h

Kno

wle

dge

/att

itud

es

on o

ral h

ealt

h

Perc

epti

on

of o

ral h

ealt

h sy

stem

Ado

lesc

ent

smok

ing

prev

alen

ce

Snac

king

pre

vale

nce

Tota

l sug

ar

cons

umpt

ion

Toot

h br

ushi

ng

habi

ts

Use

of fl

uori

date

d to

othp

aste

Ref

erra

l to

prev

enti

ve

oral

car

e

Rea

sons

for

the

last

de

ntal

vis

it

Portugal

Finland

+ +

Italy

Norway

+ + + +

Denmark

+

Sweden

+ + + + +

Netherlands

+ + + + + + +

Belgium

+ +

Greece

Austria

+ + + + + +

Germany

+ + + + + + + +

Spain

+ + + +

United Kingdom

+

France

+ + + +

Irlande

+ + + + + + + + + +

Total

6 6 5 9 4 8 5 4 2 5


149

Only four, Ireland, France, Sweden andthe Netherlands have accessible informa-tion of this nature.Interesting to note that on oral healthbehaviour, two important indicators areavailable in many countries: adolescentsmoking prevalence and sugar consump-tion. Both are important for oral health aswell as for general health. It was expectedthat information on

oral health status

(table 3)

would be commonly available

across countries, especially in respect ofthe DMFT index and the CIPTN, bothrelating to the most prevalent oral condi-tions, dental caries and periodontal dis-eases.This was confirmed for the carious mor-bidity indicators: caries free and the meannumber of decayed, missing and filledteeth per person: the DMFT index. Bothare available in 12 countries. This infor-mation is not available in Denmark, a

Table 3. Oral health status

Car

ies

free

DM

FT/d

mft

Seal

ants

Car

ies

proj

ecti

ons

Loss

of a

ttac

hmen

t

CPI

TN

Ora

l can

cer

DFA

Faci

al p

ain

Mis

sing

tee

th

Eden

tulo

usne

ss

Type

of e

xtra

cted

tee

th

Den

tal i

njur

ies

from

tra

uma

Xer

osto

mia

Portugal

+ + + + +

Finland

+ + + + +

Italy

+ + + + +

Norway

+ + + +

Denmark

+ + + +

Sweden

+ + + + + + + +

Netherlands

+ + + + + + + + + + +

Belgium

Greece

Austria

+ + + + + + + +

Germany

+ + + + + +

Spain

+ + + + + + + + + + +

United Kingdom

+ + + + + + + + + + +

France

+ + + + +

Ireland

+ + + + + + + + + + + + + +

Total

12 12 9 2 7 7 11 8 3 5 12 5 3 1

150

country where other morbidity indicatorsare used within the oral health care sys-tem. Belgium and Greece are the twoother countries with no informationavailable on caries. Either because theinformation is indeed not recorded eitherin surveys or as part as the health informa-tion system, or because this informationcould not fit within the quality criteria(reminder: codes a and b) as required by

the instructions given to fill in the ques-tionnaire.Regarding the periodontal status only 7countries, nearly half of the group, haverelevant information, either on loss ofattachment or on the CPITN index. In otherareas of oral conditions, little informationis available, with two

notable exceptions,one for oral cancer, the second on the levelof edentulousness in the population, both

Table 4a. Oral health systems: 13 indicators

Prevention, protection, oral health promotion

Administration and financing

Chi

ldre

n sc

reen

ing

cove

rage

Chi

ldre

n’s

heal

th m

onit

orin

g

Reg

ulat

ion

on fl

uori

de

Reg

ulat

ion

on p

ublic

sm

okin

g

Ave

rage

pri

ce

of t

ooth

brus

h

Ora

l hea

lth

prom

otio

n ca

mpa

ign

Tota

l pri

vate

/pub

lic O

H

expe

ndit

ures

Num

ber

of p

atie

nts

in p

riva

te p

ract

ice

Tota

l den

tist

inco

me

per

year

Num

ber

of w

orki

ng

hour

s pe

r ye

ar

Tota

l num

ber

of p

atie

nts

per

year

Tota

l num

ber

of n

ew p

atie

nts

Num

ber

of p

atie

nts

in r

egul

ar c

are

Portugal

Finland

+ + + +

Italy

Norway

+ +

Denmark

+ + + + + + + + + + +

Sweden

+ + + + + +

Netherlands

+ + + + + + + + + + + + +

Belgium

Greece

Austria

+ + +

Germany

+

Spain

+ + + + + +

United Kingdom

+ + + + +

France

Ireland

+ + + + + + + + + + + + +

Total

7 7 5 5 2 3 7 4 7 4 5 3 5


151

indicators available again in 12 countries.The information availability in oral healthsystems is shown in two tables, 4a and 4b.Table 4a covers “prevention, protectionand oral health promotion” totalizing 6indicators as well as “administration andfinancing” with 7 indicators. Apart from Ire-land and the Netherlands offering completesets of 13 indicators available, information

on oral health systems in these two areas israrely collected or accessible. Denmark,Sweden and Spain have some reliableinformation especially on administrationand financing for Denmark and on Preven-tion and oral health promotion for Swedenand Spain. All other sites are ranging fromzero indicator (France, Greece, Belgium,Italy, Portugal), to 4 in Finland, 5 in UK, 3

Table 4b. Oral health systems: 10 indicators

InterventionsPatient

satisfaction

Fiss

ure

seal

ing

Cro

wn

rest

orat

ions

Bri

dges

Impl

ants

Scal

ing

for

peri

odon

tal

trea

tmen

t

Fixe

d or

thod

onti

c ap

plia

nce

Num

ber

of t

eeth

w

ith

repl

acem

ent

of r

esto

rati

ons

Ave

rage

tim

e fo

r en

dodo

ntic

tre

atm

ent

Cos

t of

tre

atm

ent

Acc

ess

to c

are

Portugal

Finland + + + + +

Italy

Norway +

Denmark + +

Sweden + + +

Netherlands + + + + + +

Belgium

Greece +

Austria

Germany + + + +

Spain + + + + +

United Kingdom + + + + + + +

France

Ireland + + + + + + + + + +

Total 6 6 6 7 4 6 4 2 2 1

152

indicators in Austria, and 2 in Norway.The situation is no better when consider-ing the two other dimensions of oralhealth systems recorded by 10 indicators,8 qualifying “interventions” and 2 for“patient satisfaction” (table 4b).Ireland is the only one country with a com-plete data set. Again a large group is indicat-ing zero or only one indicator: France,Austria, Greece, Belgium, Norway, Italy,Portugal and Denmark with two. Informa-

tion on “patient satisfaction” is totally absentexcept for Ireland. Greece being the onlyother site with data on “cost of treatment”.Whereas quality of life as become a recog-nised component of oral health outcomesand even the expression of the “ultimate”outcome of any health system, table 5shows that this is the area in which theinformation is dramatically missing in mostcountries. The questionnaire articulated theoral health related quality of life around

Table 5. Quality of life

Functional limitation Physical painPhysical/behavioural

disability

Diffi

cult

y ch

ewin

g

Trou

ble

pron

ounc

ing

wor

ds

Toot

h do

es

not

look

rig

ht

Pain

ful g

ums

Unc

omfo

rtab

le

eati

ng

Unc

omfo

rtab

le

dent

ures

Avo

id s

mili

ng

Avo

id e

atin

g so

me

food

Spee

ch u

ncle

ar

Portugal

Finland + + + + + + + + +

Italy

Norway

Denmark

Sweden

Netherlands

Belgium

Greece

Austria

Germany + + +

Spain

United kingdom

France + + + + + + + + +

Ireland + + + + + + + + +

Total 4 4 4 3 3 3 3 3 3


153

three dimensions: function, physical pain,physical/behavioural functioning. Eachsection is comprised of three indicators.Three countries have all 9 indicators avail-able, Finland, France and Ireland. Apartfrom Germany with the three indicatorsrelating to “functional limitation”, thewhole table is blank. This seems to reflectthat with respect to data collection “qual-ity of life” is either completely ignored orwell accepted and documented in thethree dimensions indicated.

Conclusion

This preliminary consultation on the infor-mation available in 15 EU countries hasthe merit to serve as a basis for reflexionon the ability of Members States to haveavailable indicators on oral health atnational or regional level. Without tryingto give it too much scientific importance,it nevertheless reveals that the system isfacing difficulties, most of them created bythe scarcity of assigned quantitative publichealth objectives.First, a quantitative dysfunction is noted:Ireland for example, stimulated by an oper-ational surveillance system is recordingalmost all indicators proposed whereas, atthe other end, some member countriesseem to remain completely outside the sur-veillance system. From this angle, the inter-country variability on the amount of avail-able information is important. Secondly,

qualitative discrepancies are shown, due tothe difficulties encountered by some coun-tries to adapt to new knowledge and newneeds of their society. Obviously, indica-tors on “Demography and socio-economicfactors” from general sources are generallyavailable. However, information relating toquality of life, functioning of the health sys-tem, is for the majority poorly available.This situation brings forward the use of“historical” indicators, as is the case forFrance, indicators which have a priorityfocus on oral health status.This document reflects the need to initiatea broad European reflexion in the domainof health indicators and more specificallyin relation to priorities on the implementa-tion of the health surveillance programmeand public health activities. Similarly, thedocument underlines the need to updatecurrent knowledge and to harmonizeregional oral health information in orderto obtain comparable data on health sur-veillance in EU countries.The quantitative and qualitative improve-ment of oral public health informationshould be linked to national health poli-cies and public health objectives. Lastly,beyond the sole descriptive frameworkwhich provides a factual and perfectiblepicture of existing networks, a strong rec-ommendation is emerging to identify themechanisms – bridles and limits- of thesystem in relation to the production andthe use of information.

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European Oral Health Indicators Workshop on Oral health Statistics

WHO International Agency for Research on Cancer, Lyon, France4-5 September 2003

Consensus Report

Summary Report

List of Participants

157

European Oral Health Indicators. Workshop on Oral health Statistics.Consensus Report

WHO International Agency for Research on Cancer, Lyon, France4-5 September 2003

Introduction

The objectives of the EU/Project GlobalOral Health Indicators Development,project within the EU Health MonitoringProgramme, SANCO/G/3 Health Surveil-lance, 2003-2004, was to support theexchange of expectations and experiencesamong experts of oral health statistics andtheir audience, policy makers in particular.It is also to conduct a systematic review andto outline a process for identifying a set ofcore indicators for oral health that will helpprofessionals to promote and improve theglobal oral health promotion, quality ofcare and surveillance of people in Europe.To facilitate the achievements of theseobjectives, an EU/Workshop on OralHealth Statistics will be convened at Lyon,France, 4-5 September 2003. The majorobjectives of the meeting focused on:1. Identify of the health information sys-

tem problems relevant to the use of oralhealth indicators.

2. Identify of the principles for guiding theselection and use of oral health indica-tors.

3. Identify of the recent oral health indica-tor selection efforts.

44 projects leaders from the Global OralHealth Development Project and repre-sentatives from oral health institutionsattempted to the two-day meeting. Mem-bers or representatives from the steeringgroup committee were present.Representatives of the World HealthOrganisation, Geneva, representatives ofMinistries of Health -Austria, France, Fin-land, Spain, Greece, UK-, delegates of theCouncil of European Chief Dental Officers,the European Association of Dental PublicHealth, the European Society of Periodon-tology assisted as the delegates – Latvia,Hungary – from EU candidate countries.Members from European universities – Ita-lia, France, UK, Spain, Belgium- and offi-cials from dental institutions were present.List members of participants are in appen-dix.

Content of the Group sessions

Working group 1 report:

Oral health determinants, risk factors and factors of prevention

The discussion of the group addressed thefollowing issues: terminology, what logic

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should guide the selection of the indica-tors, which indicators should be retainedand the selection of a “top five list”. Inaddition the group was asked to commenton the list of indicators, derived from theECHI system that was provided prior to themeeting.

1. Definition of terms

The group had a long discussion on thedefinition of the terms “determinants”,“risk factors” and “factors of prevention”.Agreement was reached on the followingdefinitions:“Risk factors” are factors that are

directlyinvolved

in the diseases process.“Risk indicators” are the risks that are

associated

with the diseases.“Factors of prevention” are those factorsthat can be changed i.e. tooth brushinghabits.Finally the group decided to leave out theterm “determinant”.

2. Framework for selection

The group felt that the list distributed priorto the meeting was too constraining and itwas decided to follow the framework pro-posed by WHO as the STEPWISEapproach: three levels of sets of indicatorsare retained, the core, the expanded antthe optional levels.

3. Selected lists of indicators

The first list restricts the number of riskindicator/factors to those related to one ofthe most common oral disease: dental car-ies. 8 indicators have been selected:

• Social class

•

Sugar consumption

: no agreement wasreached as to whether sugar consump-tion should be recorded at individual orpopulation level.

• Past caries experience• Use of Fluoridated toothpaste• Water or Salt fluoridation• Frequency of eating and/or drinking• Brushing frequency with F. toothpaste

•

General health

(General healthincluded different diseases and func-tional disability)

Additional indicators were retained forrisk of periodontal diseases

• Use of tobacco

•

Oral hygiene techniques

•

Bleeding when brushing

•

Number of teeth present

In addition to

tobacco use

, two supple-mentary indicators would be necessary torecord risk for oral cancer:

Alcohol con-sumption

and

use of oral drugs

(chewingbetel for example).Risk for attrition/erosions could be cov-ered by recording:

Consumption of acidicdrinks

or

substances of low PH, bulimia/anorexia

Risk for Trauma/injuries:

use of mouthguards

The final “TOP 5” list

If only 5 indicators were to be recordedwhat would be the selection of the group?The outcome of the group referendumwas:

• Social class• Eating/drinking frequency (sugar con-

taining food and drinks)• Brushing frequency with fluoridated

toothpaste• Tobacco use• General health

European Oral Health Indicators. Workshop on Oral health Statistics. Consensus Report

159

It should be noted that the list is providedin this hierarchical order

5. Comments on the distributed list of indicators

The group felt that the form developedfrom the ECHI system and distributed priorto the meeting provided a list that was toolong and too broad. It was found to belacking clarity and precision in severalareas. More specific definitions are neededon point a, b, c, and d. Quality criteriashould be defined in a clearer and morehierarchical way. More detail on thesources should be provided. Finally, thegroup recommends that statement of cer-tainty should be in line with the WHOS.U.R.F. model.

Report from Working Group 2: Oral health status and Quality of life

Introduction

The topics submitted to the group discus-sion cover the 2 major outcomes dimen-sions of the process of production of oralhealth: oral health status and oral healthrelated quality of life.

1. Oral Health Status

•

ECHI derived questionnaire

:The group discussed the relevance andthe quality of the questionnaire on oralhealth indicators which had been dis-tributed to each project team for com-pletion. It was acknowledged that thequestionnaire design and content hadnot been discussed and agreed uponcollectively prior to the meeting. Thedata quality criteria were unclear andwhereas everybody did their best to

indicate what information was or wasnot available in their site, the use of thisdocumentation should be consideredas working material and not be pub-lished.

•

Methodology

:As for the definition of a list of indica-tors for recording oral health status thegroup felt that it should not try to comeup with a list of indicators per se. Ratherthe group should try to identify the mainissues and questions related to thedevelopment of such a list.The first question discussed was shouldwe record Oral health or oral diseasestatus? The group agreed that whereasthe ultimate outcome of oral care isOral health, it is oral disease status thatshould be assessed. Healthy people areof no direct interest in terms of publichealth decision making regarding improve-ment of the health care system. Costs ofcare and its reduction or containment isrelated to assessing disease trends andeffects of preventive care.As for the methodology to be used inlisting disease indicators, the group rec-ommended that the WHO STEPWISEapproach be used, thus listing three lev-els of sets: core, expanded and optionaldepending on the purpose and practicalconstraints of the information collec-tion.

• Issues related to specific diseasesrecordingThere are two main questions toanswer: how much disease do we have?How do we assess diseases?Dental Caries: should be assessed inpopulation with prevalence studies ofaffected people with repeated follow-up studies. It was felt that only activecaries should be taken into account not

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early lesions. The assessment should bedone using the DMFT index especiallythe D component. The F componentcriteria should be revisited consideringthe use of non metallic filling materials(glass ionomer and composites).Periodontal diseases: Considering thecurrent expert debate on the relevanceof existing indexes for periodontal dis-ease measurement the group agreed thatthere is a need for a consensus on a stan-dardised and simple methodology to beused throughout European countries. Itis compulsory that an assessment ofmajor risk factors be made and generalmedical information be included.For other oral diseases (i.e. mucosallesions, cancer, TMJ disorders), thegroup referred to the WHO Basic meth-ods.

• Future directions

The group suggests that all efforts bemade at the level of the oral health sys-tem to include basic medical indicatorsand vice-versa, that the medical surveysinclude some basic information on oralhealth. Another important item for thefuture should be to prioritise oral healthstatus indicators.

2. Oral Health Quality of life

• Background: Oral Health related Quality of Life(OHQOL) is generally accepted as theultimate outcome of the oral health caresystem. This concept has been con-firmed and validated cross-culturally bythe ICSII study in the context of a multinational investigation of oral healthdeterminants and outcomes. (“Compar-ing Oral Health Care Systems, a secondinternational collaborative study”,Chen et al., WHO, 1997).

However, measurement of healthrelated QOL and OHQOL is still anobject of debate especially consideringthe difficulty of its assessment in anobjective manner. Today, there is abroad consensus on the three dimen-sions of ORHQOL i.e. physical symp-toms, perceived well-being, social andphysical functioning.

• Issues addressed during the group dis-cussion:Is OHQOL a component of oral healththat should be measured in the Euro-pean context? If so, do we have alreadyexisting instruments that can be reliableand applicable in a multinational con-text, what are the measure issues/obsta-cles related to their practical applicabil-ity, what should be the next step toimplement standardised data collectionon OHQOL in European countries?

• Discussion outcomes1. There was unanimous agreement that

there is a need for measurement ofquality of life in relation to oral health.

2. The

multidimensional nature of OHQOLis acknowledged by the group. Conse-quently, there is a need for multidimen-sional instruments.

3. For measurement of OHQOL the grouprecognised that many instrumentsalready exist. Most of them have beentested for their psychometric qualitiesincluding validity and reliability. How-ever, only a few of the available instru-ments have been tested for their discri-mating qualities – their sensitivity andtheir specificity. To this effect longitudi-nal studies are needed.

4. The group felt that an instrument thatcan measure OHQOL in different Euro-pean populations is required.


161

5. The instruments selected must be easyto use.

A first step to the development of suchinstruments should start by exploring allexisting instruments. This review could bedone by a sub-group of project members.It should include a critical analysis ofexisting material.

Report from Working Group 3 – Oral Health Systems

Introduction

Working Group 3 concluded that, in gen-eral, the topics on oral health systemslisted in the questionnaire distributed tonational representatives before today’smeeting were not those for which Pan-European indicators should be developed.The working group’s members

agreed

thatthere were five areas within the topic oforal health systems that required indica-tors. All five areas could be considered as“first level” topics for oral health care sys-tems. They were:• Goals and Policies• Access and Utilisation• Effectiveness and Outcomes• Workforce• Costs

There was unanimous agreement that thereis a need for anyone considering theseareas to have knowledge of the currentnational systems for providing oral healthcare in Europe. Both the Council of Euro-pean Chief Dental Officers (CECDO) Euro-pean Liaison Committee (ELO) has pub-lished descriptions of the systems in themembers states of the European EconomicArea (European Union plus Iceland, Nor-way and Liechtenstein). The references for

these existing publications are Andersen etal. (1998) and Widström and Eaton (1999).Both publications are being updated. Thenew editions will include details of the sys-tems for the provision of oral health care inthe ten accession countries as well as theexisting member states of the EEA whenthey are published in 2004.

Goals and PoliciesThe working group agreed that all futuregoals and policies for oral health should fitwithin goals and policies for all aspects ofhealth and should be developed in collab-oration with health planners to ensure thatthey were integrated into national andEuropean health plans.Within the European Oral Health SANCOproject the working group concluded thattwo questions needed to be asked of allnational planners. These questions were:-• Is there an active national oral health

policy in your country?• If so what is it and what goals does it

contain?Once these questions have beenanswered, it should be possible to suggest“second level” indicators for national oralhealth goals and policies.

Access and UtilisationSome countries (usually those with welldeveloped publicly funded oral healthcare systems) are able to provide somedata on these topics. However, they aregenerally far from comprehensive and thefollowing “second level” indicators needto be developed in the future:• For access to oral health care at area,

regional and national level for the fol-lowing groups:-– At risk patients– Priority groups

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– Others• For the time (as opposed to distance)

that patients travel to access oral healthcare.

• For access to:-– “Preventive” care– “Curative” care

• For levels of access i.e. to:-“Preventive” care

– Basic (emergency) care– Care leading to disease eliminationand oral stability– Total care (including “cosmetic” aswell as “functional” treatment)

• For the percentage of the populationusing oral health care services withinthe previous 12 months.

Effectiveness and Outcomes

The working group were aware that theoral health care status group would beconsidering aspects of this topic andwould be making recommendations onepidemiological indicators. It thereforesought to suggest second level indicatorswhich would supplement the epidemio-logical ones and suggests that the follow-ing should be developed:• For arresting the progression of caries.• For the level of caries (from early

enamel to pulpal lesions) c.f. the systemused in Denmark.

• For the percentage of the populationnot requiring active oral health care(note – who decides this patients or cli-nicians?)

Workforce

Existing national data on workforce num-bers reported to European organisations

such as Eurostat, the Organisation for Eco-nomic Co-operation and Development(OECD), the ELO and the CECDO are notcomparable (Eaton, 2002). The reasons forthis are due to a lack of universally agreeddefinitions and lack of time and under-standing by some of those reporting thedata. In view of the European Directives,which allow freedom of movementthroughout the EU, accurate informationon workforce numbers should be a keypriority. A recent complication has beenthe development of a number of privatedental schools in Spain and Portugalwhich are likely to increase the number ofdentists graduating in these countries tosome 2,500 per annum from 2008onwards. The following informationshould be collected and reported annuallyby all EU member states for all members ofthe oral health care workforce (dentists,dental nurses, dental hygienists, dentaltechnicians (clinical and laboratory), den-tal therapists and for any new groupswhich may develop in the future:• Total numbers• Gender• Age profile• Numbers working• Hours worked per year• Area of practice e.g. general practice,

hospital, public dental service, univer-sity.

• Numbers of specialists by specialtyIn addition there is a need for annualreports from each EU member state on:• Numbers of dental schools• Numbers of other schools training

members of the dental team• Annual intake to dental and other

schools indicating gender• Annual output from dental and other

schools indicating gender


163

• Length of all training courses in hours• Whether or not continuing professional

education (CPE) is mandatory• If CPD is mandatory, how many hours

per year are required

CostsThe working group felt that the followingsecond level indicators should be devel-oped against agreed criteria and reportedannually by all EU members states:-• Total expenditure on all aspects of oral

health• Expenditure on “preventive” oral health

care• Expenditure on “curative” oral health

care• Expenditure on all aspects of education

and training• Expenditure on work produced by den-

tal technicians• Expenditure on oral health care in hos-

pitals

Other PointsThe working group were aware that most,if not all, of the suggested indicators arenot currently in use within Europeancountries and that they will need to bedeveloped. None of the existing indicatorsfor oral health systems are reliable. Whendeveloping indicators the following pointsshould be borne in mind:-• Agreement of definition of terms.• An understanding of the oral health

care systems in each member state.• The tension between harmonisation

and the reality of existing systems and apolitical will to maintain the status quo.

• Patients’ views conflicting with govern-ments’ and other funders’ views e.g.

the need to fund “cosmetic” oral healthcare.

The working group was aware that itwould be very difficult to gather informa-tion in some countries. It was suggestedone way to overcome the problem mightbe to include questions on the cost andutilisation of oral health care services inhouse hold surveys. The working groupalso felt that it would be necessary toagree which of the many indicators itwould like to see developed could bedeveloped immediately and which oneswould need to be developed in the future.

Final Point

The responses to the questionnaire onexisting national oral health indicatorswhich was distributed before today’smeeting were not discussed within theworking group. However, both the Chair-man and Rapporteur for the group suggestthat because no calibration of respondentstook place before the questionnaires weresubmitted, their accuracy may be doubtfuland that, in their present form, they shouldpurely be used for discussion within theproject and not published.

Perspectives - Conclusions

The specific objectives of the meetingwere reached on the following points:• Strengthen the ability at the local,

national, regional levels to measure,compare and determine the effects oforal health services and use ofresources

• Identify indicators of oral health (prob-lems, determinant and risk factorsrelated to lifestyles) of critical oralhealth care

• Identify the types of data generation andmanagement problems within the HIS

164

• Identify principles for guiding the selec-tion and use of OH indicators

• Identify a set of core indicators for oralhealth

• Review the recent oral health indicatorselection efforts

The next step of the programme is to pro-duce end of 2003 a compendium issuingof the meeting under the auspices of theSANCO Monitoring Programme includingall the presentations, discussions, contri-butions of the Group.

The Oral Health Indicators questionnairemust be, in accordance with the recom-mendation of the working groups, revis-ited in order to increase the precisionespecially in the field of the quality criteriawhich should be defined in a clearer andmore hierarchical way.The finalisation of the long list of the indi-cators – end of 2003- will introduce theprocesses of the Delphi consultationthrough the European network in order tosubmit an initial short list in the next Euro-pean meeting held on Granada, 8-9 May2004.

165

Summary Report

Purpose

By holding the first official internationalresearch team gathering of the EuropeanGlobal Health Indicators Development(EGOHID) project of the EU Health Moni-toring (SANCO) Programme, to launch thedynamic consultative process.

Brief summary

The meeting brought together members ofthe EGOHD Steering Group, WHO andmany collaborative institutions within theEU (agenda and participant list attached).The overall goal was to address the profu-sion of internationally recommended indi-cators for oral health which have led tounnecessary and costly monitoring efforts.The specific objectives of the meetingwere to• Strengthen the ability at the local,

national, regional levels to measure,compare and determine the effects oforal health services and use of resources

• Identify indicators of oral health (prob-lems, determinant and risk factorsrelated to lifestyles) of critical oralhealth care

• Identify the types of data generation andmanagement problems within theHealth Information System

• Identify principles for guiding the selec-tion and use of OH indicators

• Identify a set of core indicators for oralhealth

• Review the recent oral health indicatorselection efforts

Recommendations/Action to be taken:

• Statement of list indicators should be inline with the WHO S.U.R.F, NCD InfoBase model.

• International expert groups shouldreview the effectiveness and relevanceof the methodology at regular intervalsand commission auditors of surveys

• All future goals and policies for oralhealth should fit within goals and poli-cies for all aspects of health

• This will require agreement on a stan-dard minimum set of indicators suitableto measuring population levels of adultoral health

• The outcome on essentials indicatorsfor oral health determinants, risk factorsand factors of prevention by hierarchi-cal order was: Social class, eating/drinking frequency (sugar containingfood and drinks), brushing frequencywith fluoridated toothpaste, tobaccouse, and general health.

• There is a need for measurement ofquality of life in relation to oral health.

• Five areas within the topic of oral healthsystems that required indicators couldbe considered as “first level” topics fororal health care systems: Goals and pol-icies; access and utilisation, effective-ness and outcomes, workforce andcosts.

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European Global Oral Health IndicatorsDevelopment Steering Group

Professor Denis M. Bourgeois

Project Leader, Department of PublicHealth, Faculty of Dentistry, UniversityLyon I, Rue G. Paradin, Lyon, France

Professor Cesar Mexia de Almeida

Facultade de Medicina Dentaria, CitadeUniversitaria, P-1600-214 Lisboa, Portugal

Professor Thomas Hoffmann

Department of Periodontology, MedicalFaculty, University of technology of Dres-den, Fetscher Strasse, 3e 74, 01307 Dres-den, Germany

Dr. Carina Källestäl

Head of Unit, National Institute of PublicHealth, Unit for Intervention Research,Olof Palmes gata 17, SE-103 52 Stock-holm, Sweden

Professor Denis F. Kinane

University of Glasgow, Dental School,378 Sauchiehall Street, G23JZ Glasgow, U.K

Professor Juan Carlos Llodra

Facultad Odontologica, UniversisasGranada, Campus Universitario La Car-tusa, Granada, Spain

Dr. Anne Nordblad

Head of Development (oral health),Docent, Ministry of Social Affairs andHealth, Health Department, P.O Box 33,FIN-00023 Government, Finland

Professor Poul Erik Petersen (representedby Dr. Lisa Boge Christensen)

WHO Collaborating Centre for CommunityOral Health Programmes and Research,

Department of Periodontology, School ofDentistry, University of Copenhagen, 20Nörre Allé, 2200 Copenhagen, Denmark

Professor Denis O’Mullane (representedby Dr. Helen Whelton)

WHO Collaborating Centre for OralHealth Services Research. Oral HealthServices Research Centre, University Den-tal School and Hospital, University Col-lege Cork, Wilton, Cork, Ireland

Dr. Erik Skaret

Associate Professor, University of Bergen,Center for Odontophobia, Aarstadveien17, N-5009 Bergen, Norway

Professor Laura Strohmenger

WHO Collaborating Centre for Epidemiol-ogy and Community Dentistry, ClinicaOdontostomatologica, Instituto ScienzeBiomediche San Paulo, University of Milan,Via Beldiletto 1/3, 20142 Milan, Italy

Professor Jean-Pierre Van Neuwienhuysen

Université Catholique de Louvain, CliniquesUniversitaires Saint Luc, Département deMédecine Dentaire et de Stomatologie,Hippocrate Avenue S15, Brussels, Belgique

Dr. Jaap Veerkamp (Represented by DrMaddelon Lenters)

Department Pediatric Dentistry, ACTA,Louwesweg 1, NL 1066 EA Amsterdam,Netherlands

Dr. Gernot Wimmer

Universiätsklinik fur Zähn, Mund- undKieferheilkunde, Auenbruggerplatz12, A-8036 Graz, Austria


167

Guest Speakers

Professor Pierre C. Baehni

Fédération Européenne de Parodontolo-gie, Section de Médecine dentaire, Uni-versité de Genève, Rue B.Menn 19, CH.1205 Genève, Suisse

Dr. Ruth Bonita

Director, Surveillance NoncommunicableDiseases and Mental Health, WorldHealth Organization, CH-1211 Geneva27, Switzerland

Dr. Joana Carvalho

Associate Professor, Université Catholiquede Louvain, Cliniques Universitaires SaintLuc, Département de Médecine Dentaireet de Stomatologie Avenue Hippocrate 15,1200 Bruxelles, Belgique

Professor Gérard Duru

Director of Research CNRS

,

UMR 5823CNRS Bât 101 Université Lyon 1; 27, Bddu 11 novembre 1918, 69622 Villeur-banne, France

Dr. Kenneth A. Eaton

Adviser to the Council of European ChiefDental Officers, Old Saddlers, Kempe'sCorner, Boughton Aluph, TN 25 4EW Ash-ford Kent, U.K

Professor Poul Erik Petersen

Group Leader, Oral Health Programme,World Health Organization, CH-1211Geneva 27, Switzerland

Professor Paul Riordan

Dental Services, Locked Bag, Bentley D.C.WA 6983, Western Australia, Australia

Professor Eeva Widström

President of the Council of European ChiefDental Officers, Chief Dental Officer,STAKES P.O. Box 220 – Lintulahdenkuja 400531 Helsinki Finland

Others Participants

Mrs Sylvie Chartron

Scientific Affairs Manager, Masterfoods,BP 36, Haguenau cedex, France

Dr. Jacques Desfontaine

CCOMS pour le développement de nou-veaux concepts d’éducation et de pra-tiques bucco-dentaire, Union Françaisepour la Santé Bucco-dentaire, 7 rue Mari-otte, 75017 Paris, France

Dr. Alejandro Ceballos

Dean, Facultad Odontologia, CampusUniversitario, La Cartuja, Granada, Spain

Dr. Paul Karsenty

Direction Générale de la Santé, Ministère dela santé, de la famille et des personnes hand-icapées, 8, avenue de Ségur, 75007 PARIS

Professor Nigel. B. Pitts

Vice President European Association ofDental Public Health, Dental Health Ser-vices Research Unit, Dundee Dental Hos-pital and School, Park Place, DD1 4HRDundee Scotland, U.K

168

Dr. Paul Langmaid

Council of European Chief Dental Offic-ers, National Assembly for Wales, CathaysPark, CF 10 3NQ Cardiff, U.K

Dr. Henri Michelet

Président Commission Europe, ConseilNational de l'Ordre des Chirurgiens Den-tistes, 22 rue E. Menier, Paris, France

Dr. Catherine Miller

Associate Professor, Department of Odon-tology, Faculty of Dentistry, University ofParis V, 1 rue M. Arnoux, 92120 Mon-trouge France

Dr. Gianluigi Morciano

Universita Degli Studi di Pavia, Depart-ment "Biotatistica e Metodologia Epidemi-ologica", Via A. Bassi, 21, 27100 Pavia,Italy

Professor Michèle Muller-Bolla

Associate Dean, Oral Public HealthDepartment, Faculty of Odontology, Uni-versity of Nice Sophia Antipolis, 24 Ave-nue des diables bleus 06357 Nice, France

Dr Livia Ottolenghi

Preventive and Community Dentistry,Dental School, University of Rome "LaSapienza", v.le Regina Elena, 287/a

Dr. Elpida Pavi

Chief Dental Officer

,

Hellenic

Ministry ofHealth, 32 Hippocratous Street, 106 80Athens, Greece

Mrs Gabrielle Sax

Magister, Chief Dental Officers, Osterre-ichisches Bundeinstitut fur Gesund-heitswesen (OBIG), Austrian Health Insti-tute, Stubenring 6, Wien, Austria

Dr. Egita Senagola

Medical Academy of Latvia, Institute ofStomatology, 20 Dzirciema Street,LV1007 Riga, Latvia

Dr. Judit Szoke

Huba u 10, 1134 Budapest, Hungary

Dr. Alfonso Villa Vigil

President of the National Dental Spain Asso-ciation, Consejo General de Odontologos yEstomatologos de Espana C/Alcala 79, 2Planta 28009 Madrid, Spain

Adviser

Dr. Annamari Nihtilä

Sepontie 1 V, Espoo, Finland

Secretariat – EGOHID – University Lyon I

Laboratory of Analysis in Health System, UMR 5823 CNRS Université Lyon 127, Bd du 11 novembre 1918, 69622 Villeurbanne, France

Professor Jean Paul Auray

Director of Research CNRS

Dr Bruno Comte

Associate Professor

Mrs Marie Hélène Leclercq

Project coordinator

Mrs Claire Rigaud-Bully

Logistic Manager

This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of thecontractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarilyrepresent the view of the Commission or the Directorate General for Health and Consumer Protection. The EuropeanCommission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use madethereof.